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Distensibility Index: A ‘Game Changer’ in Pediatric EoE?

Measuring esophageal distensibility can help define the severity of early scarring in the esophagus of children with eosinophilic esophagitis (EoE), a new study indicates.

“Using the distensibility index (DI), a gastroenterologist can provide a quantitative measure of fibrostenotic severity, locate the narrowing, and determine the appropriate balloon size for dilation,” Joshua Wechsler, MD, medical director of the eosinophilic gastrointestinal diseases program at Lurie Children’s Hospital of Chicago, told Medscape Medical News.

“The DI has the potential to prevent emergency room visits for food impaction by intervening before narrowing is significant,” he added.

The study was published online in Clinical Gastroenterology and Hepatology.

The endoluminal functional lumen imaging probe (EndoFLIP) was used in the study to measure the DI, a functional measure of how much force is required to stretch open the esophagus.

Participants included 59 children (median age, 15 years) with EoE undergoing endoscopy and EndoFLIP at Lurie Children’s Hospital for suspected or previously diagnosed EoE.

Fibrostenotic features were present in 46% of patients, with active EoE present in 56%.

“The DI (mm2/mmHg) is identified at the distensibility plateau where diameter (at the narrowest point) doesn’t increase with increasing pressure,” Wechsler said.

The DI was significantly lower in patients with fibrotic as compared with inflammatory features on endoscopy (median 3.3 vs 5.5 mm2/mmHg, P = .02), and showed no correlation with eosinophil count.

A DI of < 4.5 mm2/mmHg predicted grade 2 rings on endoscopy with area under the curve (AUC) of 0.81 (P = .004).

“Using the 16 cm EndoFLIP catheter, we found that a DI of < 3 was grade 2+ rings 90% of the time, and a DI of < 2 was grade 2+ rings 97% of the time,” Wechsler said.

The DI provides “an objective measure of fibrostenotic severity (tightness of rings) in patients with EoE who are at least 9 years old without reliance on visual findings, which can be more subtle than in adults with dominant strictures,” Wechsler added.

The DI predicted food impaction in both unadjusted and adjusted models (fully adjusted odds ratio, 1.44, P = .0486).

At Lurie Children’s Hospital, the DI is now routinely used to inform clinical care, Wechsler said.

“This is a game changer in how we care for kids with EoE,” he said in a news release.

“Now, if distensibility is low, we can dilate the esophagus during the same procedure, and because we can pinpoint exactly where the scarring is, our intervention is more targeted and takes much less time. We are seeing improvements in symptoms, which is incredibly exciting,” Wechsler added.

Support for Routine Use

Reached for comment, David Johnson, MD, professor of medicine and chief of gastroenterology at the Eastern Virginia Medical School in Norfolk, who wasn’t involved in the study, said it “builds on growing data on the efficacy of the measurement of esophageal distension in eosinophilic esophagitis.”

“Low distensibility has significant correlation with future food impactions, which is a clinical outcome that obviously has significant morbidity,” Johnson told Medscape Medical News.

“Low distensibility is reflective of a submucosal scarring or fibrosis, which can be problematic, if not recognized, and endoscopic assessment doesn’t always recognize all the areas of scarring, so this is a great way to localize and identify it upfront, and thereby, hopefully, get a much more directed intervention to prevent some of this chronic inflammatory fibrosis,” Johnson said.

To date, distensibility measurement has been used primarily in tertiary referral centers and in academic and investigational evaluations, “but it’s not investigational,” he noted.

“Based on the growing evidence to support it, this should be in more widespread use and, in particular, for eosinophilic esophagitis in children,” Johnson said.

Funding for the study was provided by the Campaign Urging Research for Eosinophilic Diseases (CURED) Foundation. Wechsler and Johnson report no relevant financial relationships.

Clin Gastro Hepatol. Published online September 16, 2022. Abstract

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