Assessment of Esophageal Motility in Patients With Eosinophilic Esophagitis: A Scoping Review

The Dynamic Evolution of Eosinophilic Esophagitis

Eosinophilic esophagitis (EoE) is a chronic, immune-mediated inflammatory condition of the esophagus characterized by eosinophilic infiltration, and hallmark symptoms of esophageal dysfunction such as dysphagia and food impaction. Over the past three decades, EoE has been recognized as a distinct clinical entity, distinguished from gastroesophageal reflux disease (GERD) through advancements in diagnostic techniques, particularly endoscopy with biopsy. The rising global prevalence of EoE reflects enhanced diagnostic awareness, evolving criteria, and environmental along with lifestyle changes. The etiology of EoE is multifactorial, involving genetic predispositions, immune dysregulation, the gut microbiome, and environmental triggers, including dietary allergens and aeroallergens. Key mechanisms include a type 2 helper T-cell (Th2)-driven immune response, epithelial barrier dysfunction, and genetic variants such as CAPN14 and TSLP. Chronic inflammation leads to tissue remodeling, fibrosis, and esophageal narrowing, contributing to disease progression and complications. Management strategies have evolved to include dietary elimination, proton pump inhibitors, topical corticosteroids, biologics, and endoscopic interventions for fibrostenotic complications. Emerging therapies targeting cytokines such as interleukin (IL)-4, IL-5, and IL-13, alongside novel diagnostic tools like the esophageal string test and Cytosponge, offer promising avenues for improved disease control and non-invasive monitoring. Long-term surveillance combining endoscopic and histological evaluations with biomarkers and non-invasive tools is critical to optimizing outcomes and preventing complications. Future research should address gaps in understanding the role of the esophageal microbiome, refine therapeutic approaches, and develop personalized strategies to improve disease management and patient quality of life.

Clinical characteristics of patients with eosinophilic esophagitis and eosinophilic esophageal myositis based on esophageal motility

BACKGROUND

Eosinophilic esophagitis (EoE) presents with various esophageal motility disorders, and some cases of hypercontractile esophagus (HE) are associated with eosinophilic esophageal myositis (EoEM). This study aimed to compare the clinical characteristics of patients with EoE and EoEM according to their esophageal motility.

METHODS

The 28 patients with EoE and 2 patients with EoEM were divided into three groups based on esophageal motility: normal motility group, hypomotility group, and spastic contraction group. The clinical characteristics of the three groups were retrospectively compared.

RESULTS

Among the 28 patients with EoE, there were 15 with normal esophageal motility, 9 with hypomotility (2 with absent contractility, 7 with ineffective esophageal motility), and 4 with spastic contractions (1 with type III achalasia, 1 with HE, 2 with unclassifiable multipeak contractions). The two patients with EoEM had HE. Most patients in the normal and hypomotility groups had typical endoscopic findings of EoE, whereas these typical findings were less common in the spastic contraction group (P < 0.001). Four of the five patients with esophageal stricture were in the hypomotility group (P = 0.036). The therapy method significantly differed between the three groups: the normal group had more patients that responded to a proton pump inhibitor or potassium-competitive acid blocker, the hypomotility group had more patients that responded to steroids, and the spastic contraction group contained two patients treated with per-oral endoscopic myotomy (P = 0.021).

CONCLUSIONS

The endoscopic findings and therapy methods differ between patients with EoE and EoEM based on the esophageal motility.

Achalasia: beyond the basics

Achalasia is a rare oesophageal disease characterised by an unrelaxing lower oesophageal sphincter and abnormal peristalsis of the oesophageal body. Achalasia symptoms include dysphagia to solid and liquid, chest pain, regurgitation and weight loss. Achalasia diagnosis might be delayed for many years when atypical symptoms dominate. Significant progress has been made over the last two decades regarding our understanding of pathophysiology, methods of evaluation and management. The development of high-resolution manometry in particular has improved the diagnosis of achalasia, as well as other major motility disorders. Subtyping achalasia into manometric patterns has pathophysiological and therapeutic implications. Furthermore, complementary tests such as timed barium swallow and the functional lumen imaging probe (EndoFLIP; Crospon Medical Devices, Galway, Ireland) have significantly added to achalasia diagnosis algorithm and management decision-making. Progression in management has helped optimise established therapy (pneumatic dilatation and Heller myotomy) and introduced new endoscopic treatments (peroral endoscopic myotomy) and surgical techniques (surgical robotic Heller myotomy). This review will aim to shed light on the most recent advances in achalasia diagnosis, classification and management.

AGA Clinical Practice Update on Esophageal Dysfunction Due to Disordered Immunity and Infection: Expert Review

METHODS

This expert review was commissioned and approved by the American Gastroenterological Association (AGA) Institute Clinical Practice Updates Committee (CPUC) and the AGA Governing Board to provide timely guidance on a topic of high clinical importance to the AGA membership, and underwent internal peer review by the CPUC and external peer review through standard procedures of Clinical Gastroenterology and Hepatology. These Best Practice Advice (BPA) statements were drawn from a review of the published literature and from expert opinion. Since systematic reviews were not performed, these BPA statements do not carry formal ratings regarding the quality of evidence or strength of the presented considerations.

DESCRIPTION

Infectious and immune-mediated esophageal disorders are poorly understood and often under-diagnosed conditions that lead to esophageal dysfunction and health care costs due to repeated procedures and a lack of understanding of their etiology and pathogenesis. Without a high index of suspicion, these disorders may be overlooked. Esophageal dysfunction may arise from active, localized infection and immune-mediated disease (ie, candida, etc.) or from an organ-specific manifestation of a more diffuse immune-mediated disease or infection (ie, systemic sclerosis, connective tissue disease, neurologic disease). These conditions can sometimes lead to neuromuscular dysfunction and subsequent esophageal dysmotility. Awareness of local and systemic processes that lead to esophageal dysfunction will improve patient outcomes by focusing therapeutics and limiting unnecessary procedures. Therefore, the purpose of this AGA Clinical Practice Update Expert Review is to provide BPA on diagnostic considerations of immune-mediated disorders that should be considered when encountering patients with dysphagia, heartburn, and odynophagia. Best Practice Advice Statements: BEST PRACTICE ADVICE 1: Gastroenterologists should be aware of the esophageal manifestations of systemic immunologic and infectious diseases to reduce diagnostic delay. Clinicians should identify if there are risks for inflammatory or infectious possibilities for a patient's esophageal symptoms and investigate for these disorders as a potential cause of esophageal dysfunction. BEST PRACTICE ADVICE 2: Once esophageal infection is identified, clinicians should identify whether accompanying signs/symptoms suggest immunocompromise leading to a more systemic infection. Consultation with an infectious disease expert will aid in guiding appropriate treatment. BEST PRACTICE ADVICE 3: If symptoms do not improve after therapy for infectious esophagitis, evaluation for refractory infection or additional underlying sources of esophageal and immunologic dysfunction should be performed. BEST PRACTICE ADVICE 4: In individuals with eosinophilic esophagitis (EoE) who continue to experience symptoms of esophageal dysfunction despite histologic and endoscopic disease remission, clinicians should be aware that some patients with EoE may develop motility disorders. Further evaluation of esophageal motility may be warranted. BEST PRACTICE ADVICE 5: In individuals with histologic and endoscopic features of lymphocytic esophagitis, clinicians should consider treatment of lymphocytic-related inflammation with proton-pump inhibitor therapy or swallowed topical corticosteroids and as needed esophageal dilation. BEST PRACTICE ADVICE 6: In patients who present with esophageal symptoms in the setting of hypereosinophilia (absolute eosinophil count [AEC] >1500 cells/uL), consider further work-up of non-EoE eosinophilic gastrointestinal (GI) disease, hypereosinophilic syndrome, and eosinophilic granulomatosis with polyangiitis (EGPA). Consultation with allergy/immunology may help guide further diagnostic work-up and treatment. BEST PRACTICE ADVICE 7: In individuals with rheumatologic diseases of systemic sclerosis (SSc), mixed connective tissue disease (MCTD), systemic lupus erythematosus (SLE), or Sjogren's disease, clinicians should be aware that esophageal symptoms can occur due to involvement of the esophageal muscle layer, resulting in dysmotility and/or incompetence of the lower esophageal sphincter. The degree of dysfunction is often especially significant in those with SSc or MCTD. BEST PRACTICE ADVICE 8: In individuals with Crohn's disease, clinicians should be aware that a minority of individuals can develop esophageal involvement from inflammatory, stricturing, or fistulizing changes with granulomas seen histologically. Esophageal manifestations of Crohn's disease tend to occur in individuals with active intestinal disease. BEST PRACTICE ADVICE 9: In individuals with dermatologic diseases of lichen planus or bullous disorders, clinicians should be aware that dysphagia can occur due to endoscopically visible esophageal mucosal involvement. Esophageal lichen planus, in particular, can occur without skin involvement and can be difficult to define on esophageal histopathology. BEST PRACTICE ADVICE 10: Clinicians should consider infectious and inflammatory causes of secondary achalasia during initial evaluation. One should query for any history of recent COVID infections, risks for Chagas disease, and symptoms or signs of eosinophilic disease.

Swallowed topical corticosteroids for eosinophilic esophagitis: Utilization and real-world efficacy from the EoE CONNECT registry

BACKGROUND

Swallowed topical corticosteroids (tC) are common therapy for patients with eosinophilic esophagitis (EoE). Widely heterogeneous results have occurred due to their active ingredients, formulations and doses.

OBJECTIVE

To assess the effectiveness of topical corticosteroid therapy for EoE in real-world practice.

METHODS

Cross-sectional study analysis of the multicentre EoE CONNECT registry. Clinical remission was defined as a decrease of ≥50% in dysphagia symptom scores; histological remission was defined as a peak eosinophil count below 15 per high-power field. The effectiveness in achieving clinico-histological remission (CHR) was compared for the main tC formulations.

RESULTS

Overall, data on 1456 prescriptions of tC in monotherapy used in 866 individual patients were assessed. Of those, 904 prescriptions with data on formulation were employed for the induction of remission; 234 reduced a previously effective dose for maintenance. Fluticasone propionate formulations dominated the first-line treatment, while budesonide was more common in later therapies. A swallowed nasal drop suspension was the most common formulation of fluticasone propionate. Doses ≥0.8 mg/day provided a 65% CHR rate and were superior to lower doses. Oral viscous solution prepared by a pharmacist was the most common prescription of budesonide; 4 mg/day provided no benefit over 2 mg/day (CHR rated being 72% and 80%, respectively). A multivariate analysis revealed budesonide orodispersible tablets as the most effective therapy (OR 18.9, p < 0.001); use of higher doses (OR 4.3, p = 0.03) and lower symptom scores (OR 0.9, p = 0.01) were also determinants of effectiveness.

CONCLUSION

Reduced symptom severity, use of high doses, and use of budesonide orodispersible tablets particularly were all independent predictors of tC effectiveness.