Gastroenterology

Gastroenterology

Volume 145, Issue 6, December 2013, Pages 1230-1236.e2
Gastroenterology

Original Research
Full Report: Clinical—Alimentary Tract
Delay in Diagnosis of Eosinophilic Esophagitis Increases Risk for Stricture Formation in a Time-Dependent Manner

https://doi.org/10.1053/j.gastro.2013.08.015Get rights and content

Background & Aims

Development of strictures is a major concern for patients with eosinophilic esophagitis (EoE). At diagnosis, EoE can present with an inflammatory phenotype (characterized by whitish exudates, furrows, and edema), a stricturing phenotype (characterized by rings and stenosis), or a combination of these. Little is known about progression of stricture formation; we evaluated stricture development over time in the absence of treatment and investigated risk factors for stricture formation.

Methods

We performed a retrospective study using the Swiss EoE Database, collecting data on 200 patients with symptomatic EoE (153 men; mean age at diagnosis, 39 ± 15 years old). Stricture severity was graded based on the degree of difficulty associated with passing of the standard adult endoscope.

Results

The median delay in diagnosis of EoE was 6 years (interquartile range, 2−12 years). With increasing duration of delay in diagnosis, the prevalence of fibrotic features of EoE, based on endoscopy, increased from 46.5% (diagnostic delay, 0−2 years) to 87.5% (diagnostic delay, >20 years; P = .020). Similarly, the prevalence of esophageal strictures increased with duration of diagnostic delay, from 17.2% (diagnostic delay, 0−2 years) to 70.8% (diagnostic delay, >20 years; P < .001). Diagnostic delay was the only risk factor for strictures at the time of EoE diagnosis (odds ratio = 1.08; 95% confidence interval: 1.040−1.122; P < .001).

Conclusions

The prevalence of esophageal strictures correlates with the duration of untreated disease. These findings indicate the need to minimize delay in diagnosis of EoE.

Section snippets

Swiss EoE Database

We performed a retrospective analysis of the Swiss EoE database (SEED) and an extensive review of all patient records. The SEED was founded in 1989 by the senior author (AS) and currently includes data on 783 EoE patients from all over Switzerland. The data are stored in the Swiss EoE Clinic located in Olten, Switzerland. Of 783 patients, 323 patients (41.3%) are followed up and treated on a regular basis at the Swiss EoE Clinic by the senior author. In order to minimize the limitations of the

Patient Characteristics

The flow chart of the study population is shown in Supplementary Figure 1. Of 783 patients included into SEED, 323 were diagnosed by the senior author according to standardized protocols for assessment of clinical, endoscopic, histologic, and laboratory disease activity. Data on 123 patients were excluded due to either incomplete or missing information (records of 41, 37, 26, and 19 patients were missing data on the endoscopic features of EoE, symptom severity, laboratory workup, and histology,

Discussion

Stricture formation is a major complication of EoE. We were able to demonstrate that patients are more likely to present with purely inflammatory endoscopic EoE features early in the disease course and then progress to develop fibrotic endoscopic features, in addition to inflammatory features. Also, the risk of developing esophageal strictures is significantly associated with the length of diagnostic delay, a time period from appearance of first symptoms to establishment of EoE diagnosis. We

References (29)

  • A. Straumann et al.

    Eosinophilic esophagitis: analysis of food impaction and perforation in 251 adolescent and adult patients

    Clin Gastroenterol Hepatol

    (2008)
  • M.A. Kwiatek et al.

    Mechanical properties of the esophagus in eosinophilic esophagitis

    Gastroenterology

    (2011)
  • A. Bottomley et al.

    Patient-reported outcomes: assessment and current perspectives of the guidelines of the Food and Drug Administration and the reflection paper of the European Medicines Agency

    Eur J Cancer

    (2009)
  • C.A. Liacouras et al.

    Eosinophilic esophagitis: updated consensus recommendations for children and adults

    J Allergy Clin Immunol

    (2011)
  • Cited by (0)

    Author names in bold designate shared co-first authorship.

    This article has an accompanying continuing medical education activity on page e13. Learning Objective: Upon completion of this CME section, successful learners will be able to: explain the typical clinical pattern of a patient with eosinophilic esophagitis, diagnose EoE, differentiate EoE from other conditions associated with esophageal eosinophilia, and identify the key factor associated with the generation of strictures in EoE.

    Conflicts of interest The authors disclose no conflicts.

    Funding This work was supported by a grant from the Swiss National Science Foundation (grant no. 32003B_135665/1) to AMS and AS.

    Authors share co-first authorship.

    View full text