Dilation in eosinophilic esophagitis: to do or not to do?

摘要

Since its inception more than four centuries ago, esoph-ageal dilation has remained the most common form of therapy for dysphagia caused by Schatzki's rings, peptic or radiation strictures, or motility disorders such as idiopathic achalasia. Not surprisingly, esophageal dilation was one of the first therapies used for adult patients with eosino-philic esophagitis (EoE), a disease that has emerged over the past fifteen years as one of the most common causes of dysphagia and food impaction. Considerable concern arose from initial reports of complications related to esophageal dilation in EoE that included not only chest pain but also perforation. Of the 84 adult patients reported before 2008 who underwent dilation, 5% experienced an esophageal perforation and 7% were hospitalized for chest pain. Although almost all patients experienced symptomatic improvement, these complication rates are substantially higher than those quoted for esophageal dilation for other benign esophageal strictures, with the exception of pneumatic dilation for achalasia. Further compounding this concern were early reports of esophageal tears and perforations from food impactions as well as from routine diagnostic endoscopies, implicating a particular propensity for esophageal mural fragility in EoE. Coincident with these reports of procedural complications in EoE, several prospective studies and randomized, controlled trials demonstrated the efficacy of both dietary elimination and topical corticosteroids in the treatment of EoE. Symptoms, histopathology, and endoscopic features, including esophageal strictures, improved after medical and dietary therapy in both pediatric and adult cohorts. Such findings led to a consensus statement publication recommending that medical or dietary therapy for EoE be attempted before performing esophageal dilation.