Introduction

Eosinophilic oesophagitis (EoE) is a chronic, progressive type 2 inflammatory disease. Proton-pump inhibitors (PPIs), swallowed topical corticosteroids (STCs), and elimination diets have been used as standard treatments for EoE patients. However, the real-world evidence (RWE) highlighting disease burden in Europe are limited.

Aims & Methods

To assess disease burden and treatment patterns among adolescent and adult patients with EoE in real-world practice.
Medical records were retrospectively reviewed for patients (aged ≥12 years) who were newly diagnosed with EoE between 1 January 2009 and 31 December 2019 (index) in Germany, France, Spain, and the United Kingdom. Patients with a peak eosinophil (eos) count (PEC) of ≥15 eos/hpf within 90 days of the index date and ≥1 follow-up endoscopy within 24 months of the index date were included. Demographics, clinical features, treatment patterns, and health outcomes were assessed from the 12-month pre-index period to the last medical record entry or death. Disease progression was assessed via physician-defined (based on symptoms, endoscopy findings, histology, need for dilation, and food impaction) and proxy-reported outcomes (dilation performed, strictures, dysphagia, evidence of food impaction, treatment initiation in treatment-naïve patients and switching/augmentation).

Results

Overall, 385 patients were included, with 70.1%–78.1% being male; the mean age was 27.8 to 33.9 years. At EoE diagnosis, the PEC was 35.3–46.1 eos/hpf, the endoscopic appearance of the oesophagus was abnormal in 73.7%–85.6% of patients, and dysphagia was present in 59.8%–82.8% of patients. Most of the patients across all 4 countries were treated with PPIs (61.5%–91.8%), STCs (56.7%–82.3%) and elimination diets (41.4%–55.2%) after EoE diagnosis. Of the patients with available data, abnormal histology (≥15 eos/hpf) was reported in 44.8%–72.0% of patients during the first 5 years after EoE diagnosis. The abnormal endoscopic appearance of the oesophagus was observed in 34.6%–83.3% of patients after approximately 2 years of EoE diagnosis and dysphagia was present in 10.2%–25.0% of patients after 4 years of EoE diagnosis across all 4 countries. While physician-defined disease progression occurred in 6.1%–16.1% of patients, 19.4%–35.1% of patients experienced proxy-reported outcomes of potential disease progression (including oesophageal dilation performed in 10.8%–21.7% of patients) after EoE diagnosis. An overview of patient and clinical characteristics at EoE diagnosis and treatment patterns and disease progression (physician-defined and proxy-reported) after EoE diagnosis across Germany, France, Spain, and the United Kingdom is provided in the Table.

Conclusion

Adolescent and adult patients with EoE chronically experienced substantial disease burden. A subset demonstrated disease progression, perhaps underrecognised despite treatment with PPIs, STCs, and elimination diets. Hence, successful EoE management may include proactive disease monitoring, treating underlying pathophysiology and prescribing maintenance therapies to achieve long-term clinical remission.

References

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Disclosure

Ulrike von Arnim: Consulting and/or speaker fees from Dr. Falk Pharma, Sanofi, Astra Zeneca, EsoCap, Abbvie, Janssen, Takeda, Pfizer, Bristol Myers Squibb.
Frank Zerbib: Consulting and/or speaker fees from Sanofi, Dr Falk pharma, Bristol Myers Squibb, Bioprojet, AstraZeneca.
Tiffany Pela, Juby A. Jacob-Nara, Gaelle Le-Bagousse-Bego, Sarette T. Tilton: Employees of Sanofi; may hold stocks and/or stock options in the company.
Bram P. Raphael, Amr Radwan, Ryan B. Thomas: Employees of Regeneron Pharmaceuticals, Inc.; may hold stocks and/or stock options in the company.
Rohan C. Parikh, Fareedat Bello: Employees of RTI Health Solutions, which received research funding from Sanofi to design and execute this study.
Funding: This study was sponsored by Sanofi and Regeneron Pharmaceuticals, Inc.
Acknowledgement: Medical writing support was provided by Akshata Rao and Ali Nasir Siddiqui, PhD, of Sanofi.

Introduction

The impact of achieving endoscopic remission in ulcerative proctitis (UP) is unclear. The preferred long-term treatment goal in ulcerative colitis (UC) is achieving both the symptomatic resolution and endoscopic remission (ER),¹ which has been associated with reduced risk of complications, including colectomy.^2,3 UP is an anatomically limited form of UC, involving only the rectum. Unlike in extensive or left-sided UC, UP has not been associated with elevated colorectal cancer risk. Therefore, the achievement of endoscopic healing as compared to clinical remission in UP represents an uncertain therapeutic target.⁴

Aims & Methods

This study assessed the impact of achieving EH on subsequent outcomes in UP patients. This was a single-center retrospective cohort study including patients aged ≥ 18 with a confirmed diagnosis of UP based on clinical and endoscopic criteria. Included patients had at least two endoscopies and active endoscopic disease (Mayo endoscopy score [(MES) of 1, 2, or 3]) at the first (baseline) endoscopy. EH was defined as an MES of 0 or 1 at the second (follow-up) procedure. A minimum time of 1 month between scopes was required for inclusion. Descriptive statistics were used for baseline characteristics. The relationship of EH to IBD-related outcomes was assessed using univariate analysis (Pearson's Chi-squared test; Fisher's exact test; Welch Two Sample t-test) and we identified those independently associated with EH using multivariable logistic regression analysis (odds ratio with 95% confidence interval).

Results

Among 200 UP patients with baseline endoscopic activity, 109 patients (54.5%) achieved EH at follow-up. The median time from baseline to follow-up was 15 months (IQR: 6, 31). EH at follow-up was significantly associated with fewer IBD-related ED visits (healing: 8.3%, no healing: 21%) or hospitalizations (5.5% vs 18%) and fewer GI visits (mean: 8 [SD: 9], vs 17 [22]) after the second scope. Patients with EH were less likely to have iron deficiency anemia (IDA; 23% vs 41%), iron infusion (10% vs 25%), C. difficile infection (0.9% vs 6.6%), or to initiate a new biologic after relapse (15% vs 33%). Patients with EH also had a greater time to clinical relapse (650 days [730] vs 270 days [416]). In multivariable analysis, patients with mucosal healing had 68% lower odds of an IBD-related ED visit (OR: 0.32, 95% CI: 0.13, 0.73), 74% lower odds of IBD-related hospitalization (0.26 [0.09, 0.67]), and 64% lower odds of biologic initiation after relapse (0.36 [0.13, 0.95]) compared to patients with no mucosal healing, adjusting for the index MES score.

Conclusion

UP patients with endoscopic healing had less IBD-related healthcare utilization (ED visits, hospitalizations, GI visits), fewer IBD-related complications (IDA, iron infusion, C. difficile infection), and were less likely to escalate to biologics after relapse. Our findings suggest that using a treatment target of endoscopic healing is desirable in UP and shed light on its potential utility in preventing disease-related complications and improving long-term outcomes.

References

1. Peyrin-Biroulet L, Sandborn W, Sands BE, et al. Selecting Therapeutic Targets in Inflammatory Bowel Disease (STRIDE): Determining Therapeutic Goals for Treat-to-Target. Off J Am Coll Gastroenterol ACG. 2015;110(9):1324-1338. doi:10.1038/ajg.2015.233
2. Colombel JF, Rutgeerts P, Reinisch W, et al. Early Mucosal Healing With Infliximab Is Associated With Improved Long-term Clinical Outcomes in Ulcerative Colitis. Gastroenterology. 2011;141(4):1194-1201. doi:10.1053/j.gastro.2011.06.054
3. Impact of mucosal healing on long‐term outcomes in ulcerative colitis treated with infliximab: a multicenter experience - Laharie - 2013 - Alimentary Pharmacology & Therapeutics - Wiley Online Library. Accessed September 24, 2022. https://onlinelibrary.wiley.com/doi/full/10.1111/apt.12289
4. Zhou Q, Shen ZF, Wu B sheng, et al. Risk of Colorectal Cancer in Ulcerative Colitis Patients: A Systematic Review and Meta-Analysis. Gastroenterol Res Pract. 2019;2019:1-11. doi:10.1155/2019/5363261

Disclosure

E.L., A.A.: no conflicts of interest to disclose
R.B.: Consulting/Speaker: Janssen, Abbvie, Bristol Myers Squibb, Prometheus Laboratories, Pfizer, Takeda
R.L.: Consulting/Speaking Fees: Pfizer, Enzymetrics, Ancilia Biosciences. Grant Support: National Institute of Health (NIH)
E.S.: Consulting/Speaking Fees: AbbVie, Crohn’s and Colitis Foundation of America (CCFA), Entera Health, Evidera, GI Health Foundation, Janssen, Protagonist Therapeutics, Seres Health, Takeda Pharmaceuticals, Bristol Myers Squibb. Grant Support: Abbott (AbbVie), AstraZeneca, CCFA, Janssen Research & Development, Johns Hopkins University, National Institute of Diabetes and Digestive and Kidney (NIDDK), National Institute of Health (NIH), New York Crohn’s Foundation, Pfizer, UCB, UCSF–CCFA Clinical Research Alliance, Genentech, Seres Therapeutics, Celgen. R.B.: Consulting: Prometheus
D.L.: Consulting/Speaking Fees: Abbvie, Boehringer Ingelheim, Eli Lilly, Fresenius Kabi, Janssen, Palatin, Pfizer, Prometheus Biosciences, Takeda; Grants: Abbvie, Janssen, Takeda

Introduction

Esophageal food bolus obstruction (FBO) is a common presentation to Emergency Departments worldwide¹. There remains a paucity of data relating to efficacy of pre-endoscopic and endoscopic management resulting in a wide variety of clinical practice. Consensus guidelines do not advocate strongly for pre-endoscopic medications however they remain commonly used^2,3. This study evaluated the safety and efficacy of pre-endoscopic and endoscopic treatment in successful clearance of FBO and assessed the prevalence of underlying esophageal pathology.

Aims & Methods

ICD-10 codes retrospectively identified adult patients ≥18 years admitted to the Monash Health network (Melbourne, Australia) with esophageal FBO from 2010 to 2021. Medical records were reviewed to determine baseline characteristics, medical and endoscopic treatments and outcomes. Pre-endoscopic therapies included glucagon, glyceryl trinitrate (GTN), buscopan and Coca Cola. Multivariable analysis was performed to determine factors associated with pre-endoscopic clearance of FBO.

Results

608 patients were included. The median age was 56 years (IQR 39 – 71) and 405 (66.6%) were male. A prior history of FBO was noted in 228 (37.5%) patients, 110 (18.1%) had gastro-oesophageal reflux disease, 71 (11.7%) had dysphagia and 51 (8.4%) had a history of esophageal strictures. Inability to swallow saliva was noted in 296 (49.7%) patients at presentation.
Pre-endoscopic therapy was administered to 389 (64.0%) patients with a mean of 2 medications prescribed. Glucagon (47.4%), GTN (37.2%) and Coca Cola (36.3%) were most commonly administered. Successful FBO clearance was documented in 36.8% patients receiving medical therapy (glucagon 35.1%, GTN 36.2%, Coca Cola 38.0%); no individual medication significantly reduced the need for endoscopic intervention. Multi-variable analysis demonstrated that tolerating saliva (OR 1.95, p=0.025) and liquids (OR 2.28, p=0.001) significantly predicted spontaneous resolution of the EFBO without endoscopy.
474 (78.0%) patients proceeded to endoscopy. Median time to endoscopy was 14 hours (IQR 6 – 16) with 36.1% patients intubated for the procedure. The FBO was most commonly located in the lower esophagus (32.7%). The most common endoscopic findings were esophagitis (30.2%) and peptic ulcer disease (18.8%), with 3 (0.6%) malignancies identified. Endoscopic complications occurred in 35 (7.4%) patients (partial esophageal tear (n=24), aspiration pneumonia (n=5)). At endoscopy, a cause for the FBO was found in 130 (27.4%) patients, most commonly due to esophageal strictures (13.9%), eosinophilic esophagitis (11.2%) and Schatzki rings (9.1%). Esophageal biopsies were taken in 155 (32.7%) patients, of which 34.2% reached the diagnostic criteria for eosinophilic esophagitis.

Conclusion

Despite limited evidence, pre-endoscopic medical treatment of FBO is safe, commonly utilised, and results in spontaneous clearance in 36.8% patients. Patients’ clinical symptoms, in particular the ability to tolerate saliva or liquids, is the best predictor for spontaneous FBO clearance. Endoscopy remains highly effective and has a low complication rate.

References

1. Longstreth GF, Longstreth KJ, Yao JF. Esophageal food impaction: Epidemiology and therapy. A retrospective, observational study. Gastrointest Endosc. 2001;53(2):193-198. doi:10.1067/mge.2001.112709
2. Ikenberry SO, Jue TL, Anderson MA, et al. Management of ingested foreign bodies and food impactions. Gastrointest Endosc. 2011;73(6):1085-1091. doi:10.1016/j.gie.2010.11.010
3. Birk M, Bauerfeind P, Deprez P, et al. Removal of foreign bodies in the upper gastrointestinal tract in adults: European Society of Gastrointestinal Endoscopy (ESGE) Clinical Guideline. Endoscopy. 2016;48(05):489-496. doi:10.1055/s-0042-100456

Introduction

The incidence of caustic ingestion has remained stable in recent years due to its difficult prevention and limited changes in its management.

Aims & Methods

Aims:
1. To explore changes in the epidemiological and clinical characteristics of caustic ingestion over the last decades
2. To identify epidemiological risk factors of adverse outcomes.
Methods: We present data from an observational study that prospectively collected caustic ingestions in our centre since 1995 and included all adult patients whose acute episode was evaluated in the emergency department. Epidemiological data and variables related to the type of ingestion, prognostic risk factors and the adverse outcomes, defined as the need for admission to the intensive care unit, emergency surgery, patient death and oesophageal or gastric stricture development, were analysed; the results were compared for the periods 1995-2009 and 2010-2024.

Results

A total of 582 episodes of caustic ingestion were included, 305 during the first period and 277 during the second.
Epidemiological characteristics and type of ingestion were overall similar in both periods, as were the clinical, analytical, endoscopic and radiologic indicators of severity.
Adverse outcomes were also similar in the two time periods, both in the short term (comparable frequency of intensive care unit admission, need for surgery and death) and in the long term (stricture development).
The main risk groups for severe ingestions were patients older than 45 years (OR 4.3; 95%CI: 2.3-7.9) and psychiatric comorbidity (OR 5.2; 95%CI: 3.0-9.1), especially depressive syndrome (OR 7.2; 95%CI: 4.2-12.4).
Recurrent ingestions were more frequent in men (OR 1.9; 95%CI: 1.0-3.5) and psychiatric illness (OR 7.6; 95%CI: 3.5-16.5), mainly personality disorder (OR 11.0; 95%CI: 5.5-21.9).

	1995-2009	2010-2024	p value
Women	164 (53,8)	133 (48,0)	0,192
Age	44 (30)	50 (30)	0,193
Voluntary intake	154 (50,5)	121 (44,0)	0,139
pH of caustic Strong acid Weak acid Weak alkali Strong alkali	50 (16,9) 17 (5,8) 215 (72,9) 13 (4,4)	40 (14,7) 25 (9,2) 200 (73,3) 8 (2,9)	0,318
Psychiatric illness Depression Bipolar disorder Personality disorder Psychotic disorder Alcohol/toxic substances consumption	155 (50,8) 112 (36,7) 5 (1,6) 28 (9,2) 16 (5,2) 23 (7,5)	119 (43,0) 75 (27,1) 11 (4,0) 20 (7,2) 13 (4,7) 26 (9,4)	0,007 0,016 0,143 0,479 0,908 0,515
Intensive care unit admission	40 (13,1)	29 (10,5)	0,391
Emergency surgery	8 (2,6)	10 (3,6)	0,655
Death	15 (4,9)	19 (6,9)	0,412
Stricture formation	11 (5,1)	8 (3,7)	0,624

Conclusion

No relevant changes were identified in the epidemiological and clinical characteristics of caustic ingestions over the last decades, nor in their evolution. The most vulnerable groups to prioritise prevention measures would be patients with psychiatric cormobility.

Introduction

Endoscopy abnormalities of eosinophilic esophagitis (EoE) are currently graded based on the EoE endoscopic reference score (EREFS) ranging 0 to 9. Research has shown that esophageal biopsies are often omitted in Europe in patients reporting dysphagia when the upper endoscopy (EGD) shows no abnormalities [1]. However, a proportion of patients with eosinophilic esophagitis (EoE) may have normal endoscopy (i.e., EREFS=0), making the diagnosis more difficult and increasing the risk of diagnostic delay.

Aims & Methods

We investigated predictors of a diagnosis of EoE when the EGD is unremarkable (i.e., EREFS=0). Consecutive adult patients (≥18 years) with dysphagia who had EREFS=0 at an EGD with six esophageal biopsies were prospectively enrolled. All patients underwent EGD while off any eosinophil-depleting treatment. EoE with EREFS=0 was diagnosed based on the presence of at least 15 eosinophils/high-power field in at least one of six esophageal biopsies. When all six esophageal biopsies showed <15 eosinophils/high-power field, patients were diagnosed with non-EoE dysphagia (NED). Demographics, diagnostic delay (i.e., interval time between symptoms onset and diagnosis), esophageal symptoms, and atopic comorbidities (i.e., allergic rhinitis, asthma, eczema) were collected for all patients. Pearson's Chi-squared test and Fisher's exact test were used for comparisons. Odds ratios (ORs) were calculated to quantify associations between disease states. Significance threshold was set at p<0.05.

Results

Of 133 included patients, 51 (38%) had NED, while 82 (62%) had EoE with EREFS=0. Patients with EoE were more commonly males (67% vs 35%; p<0.001) and younger (37 vs 46 years; p=0.005) compared to patients with NED. Patients with EoE were diagnosed with a significantly longer diagnostic delay than NED (28 vs 4 months; p<0.001). Heartburn, regurgitation, chest pain and dyspepsia had similar prevalence in the two groups. In contrast, patients with EoE had a significantly higher prevalence of atopic comorbidities compared to NED (83% vs 39%; p<0.001).
The presence of rhinitis, diagnostic delay longer than 12 months, any atopic comorbidity, age younger than 37 years, and male sex were associated with an increased risk of EoE with OR of 47.0, 11.6, 7.4, 3.8, and 3.7, respectively (p<0.01 for all).

Conclusion

EoE remains a possible diagnosis in patients reporting dysphagia even when endoscopy is normal. The presence of rhinitis and longer diagnostic delay, the presence of any atopic comorbidity, and younger age are associated with a diagnosis of EoE and are helpful to raise the suspicion of EoE and prompt endoscopists to collect esophageal biopsies.

References

[1] Tourlamain, G., Garcia-Puig, R., Gutiérrez-Junquera, C., Papadopoulou, A., Roma, E., Kalach, N., Oudshoorn, J., Sokollik, C., Karolewska-Bochenek, K., Oliva, S., Strisciuglio, C., Bauraind, O., Auth, M. K., Thomson, M., Otte, S., Rok, O., Dias, J. A., Tzivinikos, C., Urbonas, V., Kostovski, A., … ESPGHAN EGID Working group (2020). Differences in Management of Eosinophilic Esophagitis in Europe: An Assessment of Current Practice. Journal of pediatric gastroenterology and nutrition, 71(1), 83–90. https://doi.org/10.1097/MPG.0000000000002672