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Sa1663 Characterization of Dysphagia Associated Eosinophilic Esophagitis (EoE) in Children With & Without Food Impaction
Abstracts
abdominal pain (NZ30), acute pancreatitis (NZ42), choledocholithiasis (NZ31), jaundice (NZ23), acute cholangitis (NZ3), pancreaticolith (NZ2). Endoscopic sphincterotomy was performed in 43 patients and 34 patients received surgical treatment. Seven patients experienced complications after operations but all of them improved after acute management. Conclusion: AUPBD was associated with various pancreatobiliary diseases in childhood. The appropriate management including ERCP as bridging therapy and surgical treatment showed good short-term clinical outcomes.
Sa1661 Long Term Outcome of Endoscopic Sphincterotomy for Pancreaticobiliary Diseases in Pediatric Patients: a Single-Center Experience DA-I Jung*, Hyun Jin Kim, Jin MIN Cho, Seak Hee OH, Kyung Mo Kim Pediatrics, Asan Medical Center Children’s Hospital University of Ulsan College of Medicine, Seoul, Korea (the Republic of) Background: The use of endoscopic sphincterotomy (ES) is increasing in the treatment of pancreaticobiliary disease in children. However, long-term results of ES are limited in pediatric patients. The aim of this study was to assess demographic characteristics, indications, long-term outcome of ES for pancreaticobiliary diseases in pediatric patients. Methods: Between June 1994 and June 2013, 162 pediatric patients underwent 172 ES at Asan Medical Center Children’s Hospital. Thirteen patients followed up less than 1 year were excluded from this study. We analyzed demographic characteristics, indications, and long-term outcome of ES retrospectively. Results: Long term information was available in 162 patients with a median overall follow-up duration of 45 months (range, 12-186 months). The mean age of the 162 patients was 9.04.9 years (range, 1.5-17.0 years). Indications for biliary sphincterotomy included Choledochal cysts in 47, choledocholithiasis in 34, sclerosing cholangitis with CBD stone or CBD stricture in 2, biliary stenosis in 6, and other condition in 5. Indication for pancreatic sphincterotomy included acute pancreatitis in 5, acute recurrent pancreatitis in 28, chronic pancreatitis in 30, pancreatic mass in 3, and pancreatic trauma in 2. Ten of 162 patients (6%) developed late complications, including stone recurrence and/or cholangitis (nZ4) and endoscopic sphincterotomy restenosis (nZ6). Most complications improved under repeat endoscopic sphincterotomy, stone removal, and/or supportive care. Pancreaticobiliary malignancies or deaths did not occur during follow-up period. Conclusion: Approximately only 6% of patients develop late complications; therefore, endoscopic retreatment may be safe and effective. ES is a reasonable and viable method for treating pancreaticobiliary diseases, even in pediatric patients.
Sa1662 Dilation Outcomes in Pediatric Eosinophilic Esophagitis Calies Menard-Katcher*1,2, Glenn Furuta1,2, Robert Kramer1,2 1 Pediatrics, University of Colorado School of Medicine, Aurora, CO; 2 Digestive Health Institute, Childrens Hospital Colorado, Aurora, CO Background: A wide variety of practice patterns exist regarding the management of complicated pediatric Eosinophilic Esophagitis (EoE). Whereas initial adult studies examining dilation raised concerns for high rates of perforation (up to 8%) and hospitalization for pain control, subsequent reports demonstrate perforation rates similar to that observed in non-EoE patients (0.3%).1 These studies identify a role for therapeutic dilation in the management of complicated EoE in adults but the practice of dilation in pediatric EoE has been limited. The aim of our study was to report our experiences with dilation in the management of severe dysphagia in pediatric EoE patients. Methods: Using an Endoworks and EPIC search strategy, we identified patients seen at our institution between July 2010 and October 2014 who underwent upper endoscopy with esophageal dilation. From these patients, we identified those with history of esophageal eosinophilia. Medical records were further reviewed for demographic, clinical, endoscopic and radiologic information. Adverse events from dilation were captured and confirmed using a prospective procedure log. This study was approved by the local IRB. Results: During the study period, 332 total dilations were performed with a complication rate of 6.3% for any level of complication. Fortyseven dilations were performed in 33 patients with esophageal eosinophilia or confirmed EoE; who were a mean age 13.5 years old (SD 3.9 years), 72.7% male and 97% Caucasian. Dilations were accomplished with non-wire-guided Maloney dilators (76.6%) and through-the-scope balloons (23.4%). Thirty-six (76.6%) had mucosal split in response to dilation. The majority of patients had a single dilation (n Z 24, 72.7%). Nine patients required repeat dilation within the follow up period (mean 15.5 months, range 0 to 61 months) with an average of 2.6 dilations per patient (range 2 to 4). At time of dilation, patients were on a variety of other therapies for EoE including swallowed steroids (21.2%), diet restriction (6.1%) or combined therapy (18.2%). Nineteen (57.6%) were on PPI. Seven (21.2%) were not on medical therapy. The most common procedural complication was pain (n Z 7, 14.9%). Of those with pain, 6 received reassurance without sequel. One patient (2.1%) was admitted for observation. There were no perforations or other urgent evaluations as a result of esophageal dilation in this population. Conclusions: Dilation for management of dysphagia in EoE can be performed safely in children. Post procedural pain was common (19.4%) in the setting of resultant mucosal split from esophageal dilation.1 M.E. Bohm, J.E. Richter. Review article: oesophageal dilation in adults with eosinophilic oesophagitis. Aliment Pharmacol Ther, 33 (2011), 748-757.
www.giejournal.org
Sa1663 Characterization of Dysphagia Associated Eosinophilic Esophagitis (EoE) in Children With & Without Food Impaction Thirumazhisai S. Gunasekaran*1,2, Alan Schwartz2, James Berman2,3, Vaishali Bothra1, Mohamad Hatahet1, Irfan H. Siddiqui1, Vijayalakshmi Kory1 1 Advocate Lutheran General Childrens Hospital, Park Ridge, IL; 2Dept of Pediatrics, University of Illinois, Chicago, IL; 3Pediatrics, Loyola University Medical School, Maywood, IL EoE in children has been associated with a variety of symptoms, Consensus-2011 statement classifies patients into 4 groups based on predominant symptom, EoEdysphagia( D), abdominal pain (AP), GERD and failure to thrive. In a previous presentation we showed the outcome of EoE- AP is suboptimal compared to EoE- D. Now within the EoE- D group we looked to see if there is a difference in patients presenting with and without food impaction. Aim: Compare clinical features, endoscopy+ biopsy, and outcomes of EoE - D patients presenting with and without food impaction.: In this retrospective study, patients with EoE-D seen between 9/ 2005 and 7/2012 were stratified into; Group I, with food impaction and Group II, without food impaction. Physical findings, CBC, CMP, esophagram, EGD+ biopsies of the duodenum, antrum, distal and mid esophagus were captured. Diagnosis of EoE was made as per the consensus guidelines. Treatments included dietary modification and topical or oral steroids, alone or in combination. Clinical outcome was measured as improved, worsened or same. Results: Patients; Gr I 18, Gr II 18, mean age 14.77 , 14.83. Following were similar in both groups; regurgitation ( 5%), heart burn ( 22%), physical examination, CBC and CMP . Following were different in Gr I and II respectively; male predominance ( 72%, 78 %), abdominal pain: 5 and 28%, vomiting: 11 and 5%, early satiety: 5 and 0%. Esophagram; Gr I; 6 done and 3 had eso narrowing, Gr II: 6 done and 4 had narrowing . EGD ( Gr I and II) ; edema 33%, 44%; rings 22%, 16%, exudates both 44%, furrows 66%, 55%. There were no statistical difference with in the two groups. Biopsy; Gr I and II; mean peak esosinophil count 59.33 , and 40.11, eos.microabscess 22%, 39%, basal epithelial hyperplasia 50%, 33 %, spongiosis both 16%. All patients with food impaction required endoscopic removal and there were no perforations.Follow up done upto 7.6 years.With treatment Gr I and II had; 55% , 39% symptomatic improvement. 6/18 patients in Gr I and 7/18 in Gr II had a follow up EGD and the mean peak eos count was 54.3 and 30.1 respectively. 2/ 18 patients in Gr I had recurrence of food impaction and none in Gr II developed food impaction. Conclusion: By definition, both groups had dysphagia as the predominant symptom. There were no significant differences in the clinical features, endoscopic findings and outcome of the two groups. However, the peak eosinophil count was higher in the food impaction group, at presentation and follow up, suggesting more inflammation in this group. On follow up minority of food impaction group had recurrence of food impaction. The EoE-D food impaction group, with its increased inflammation and resulting in secondary dysmotility, may require more aggressive therapy. More prospective studies with larger numbers are needed to validate these data.
Sa1664 The First Case Report of Esoflip for Dilation of a Pediatric Esophageal Stricture Richard A. Lirio*1, Pradeep Nazarey2, John O’Dea3, Jenifer R. Lightdale1 1 Pediatric Gastroenterology/Hepatology/Nutrition, UMASS Memorial Children’s Medical Center, Worcester, MA; 2Pediatric Surgery, UMASS Memorial Children’s Medical Center, Worcester, MA; 3Crospon, Dangan, Ireland Treatment of benign strictures associated with eosinophilic esophagitis (EoE) in children typically involves balloon dilation with fluoroscopy as an effective, but imprecise means of widening the esophageal luminal diameter that requires radiation exposure. EsoFLIP is a novel technology that integrates multiple adjacent impedence planimetry electrodes into a dilation balloon as a means of precisely targeting dilation diameters without need for fluoroscopy. Aim: To test the technical feasibility of EsoFLIP for dilation of a benign stricture associated with EoE in a pediatric patient. Methods: We obtained informed consent/assent to use the EsoFLIP ES-320 dilation balloon (Crospen, Galway, Ireland) to evaluate and treat a 17 year old male with a history of food impactions and a significant stricture on barium swallow (Fig 1a). We compared real-time measurements pre- and post- dilation obtained using EsoFlip with traditional fluoroscopic images using Omnipaque contrast solution (300mgI/ml) (NDC 0407-1413-61, GE Healthcare). The EsoFLIP balloon was inflated using 20 ml at a gentle inflation rate of 20ml/min. The balloon was introduced under endoscopic visualization, and approximately centered within the narrowed region of the esophagus. The endoscope was then retracted to remain in the upper esophagus proximal to the balloon for the duration of the procedure. Our goals were to obtain precise measures of (1) normal esophageal lumen; (2) the waist of the stricture pre-dilation, and (3) the degree of recoil post-dilation. Dilation success was defined as achievement post-recoil of a target diameter. Results: The EsoFLIP balloon dilator was safely deployed in our patient without complication. The proximal esophagus was measured using EsoFLIP to be approximately 18 mm in diameter, while the waist was approximately 10.2 mm in diameter. (Fig 1a) Dilation was targeted to a lumen opening diameter of 15 mm, and was achieved by injecting 29 ml of fluid until the waist was measured to be 15 mm. (Fig 1b) After deflation of the balloon to 20 ml volume, we assessed the degree of recoil and found a 17%
Volume 81, No. 5S : 2015 GASTROINTESTINAL ENDOSCOPY AB299
abdominal pain (NZ30), acute pancreatitis (NZ42), choledocholithiasis (NZ31), jaundice (NZ23), acute cholangitis (NZ3), pancreaticolith (NZ2). Endoscopic sphincterotomy was performed in 43 patients and 34 patients received surgical treatment. Seven patients experienced complications after operations but all of them improved after acute management. Conclusion: AUPBD was associated with various pancreatobiliary diseases in childhood. The appropriate management including ERCP as bridging therapy and surgical treatment showed good short-term clinical outcomes.
Sa1661 Long Term Outcome of Endoscopic Sphincterotomy for Pancreaticobiliary Diseases in Pediatric Patients: a Single-Center Experience DA-I Jung*, Hyun Jin Kim, Jin MIN Cho, Seak Hee OH, Kyung Mo Kim Pediatrics, Asan Medical Center Children’s Hospital University of Ulsan College of Medicine, Seoul, Korea (the Republic of) Background: The use of endoscopic sphincterotomy (ES) is increasing in the treatment of pancreaticobiliary disease in children. However, long-term results of ES are limited in pediatric patients. The aim of this study was to assess demographic characteristics, indications, long-term outcome of ES for pancreaticobiliary diseases in pediatric patients. Methods: Between June 1994 and June 2013, 162 pediatric patients underwent 172 ES at Asan Medical Center Children’s Hospital. Thirteen patients followed up less than 1 year were excluded from this study. We analyzed demographic characteristics, indications, and long-term outcome of ES retrospectively. Results: Long term information was available in 162 patients with a median overall follow-up duration of 45 months (range, 12-186 months). The mean age of the 162 patients was 9.04.9 years (range, 1.5-17.0 years). Indications for biliary sphincterotomy included Choledochal cysts in 47, choledocholithiasis in 34, sclerosing cholangitis with CBD stone or CBD stricture in 2, biliary stenosis in 6, and other condition in 5. Indication for pancreatic sphincterotomy included acute pancreatitis in 5, acute recurrent pancreatitis in 28, chronic pancreatitis in 30, pancreatic mass in 3, and pancreatic trauma in 2. Ten of 162 patients (6%) developed late complications, including stone recurrence and/or cholangitis (nZ4) and endoscopic sphincterotomy restenosis (nZ6). Most complications improved under repeat endoscopic sphincterotomy, stone removal, and/or supportive care. Pancreaticobiliary malignancies or deaths did not occur during follow-up period. Conclusion: Approximately only 6% of patients develop late complications; therefore, endoscopic retreatment may be safe and effective. ES is a reasonable and viable method for treating pancreaticobiliary diseases, even in pediatric patients.
Sa1662 Dilation Outcomes in Pediatric Eosinophilic Esophagitis Calies Menard-Katcher*1,2, Glenn Furuta1,2, Robert Kramer1,2 1 Pediatrics, University of Colorado School of Medicine, Aurora, CO; 2 Digestive Health Institute, Childrens Hospital Colorado, Aurora, CO Background: A wide variety of practice patterns exist regarding the management of complicated pediatric Eosinophilic Esophagitis (EoE). Whereas initial adult studies examining dilation raised concerns for high rates of perforation (up to 8%) and hospitalization for pain control, subsequent reports demonstrate perforation rates similar to that observed in non-EoE patients (0.3%).1 These studies identify a role for therapeutic dilation in the management of complicated EoE in adults but the practice of dilation in pediatric EoE has been limited. The aim of our study was to report our experiences with dilation in the management of severe dysphagia in pediatric EoE patients. Methods: Using an Endoworks and EPIC search strategy, we identified patients seen at our institution between July 2010 and October 2014 who underwent upper endoscopy with esophageal dilation. From these patients, we identified those with history of esophageal eosinophilia. Medical records were further reviewed for demographic, clinical, endoscopic and radiologic information. Adverse events from dilation were captured and confirmed using a prospective procedure log. This study was approved by the local IRB. Results: During the study period, 332 total dilations were performed with a complication rate of 6.3% for any level of complication. Fortyseven dilations were performed in 33 patients with esophageal eosinophilia or confirmed EoE; who were a mean age 13.5 years old (SD 3.9 years), 72.7% male and 97% Caucasian. Dilations were accomplished with non-wire-guided Maloney dilators (76.6%) and through-the-scope balloons (23.4%). Thirty-six (76.6%) had mucosal split in response to dilation. The majority of patients had a single dilation (n Z 24, 72.7%). Nine patients required repeat dilation within the follow up period (mean 15.5 months, range 0 to 61 months) with an average of 2.6 dilations per patient (range 2 to 4). At time of dilation, patients were on a variety of other therapies for EoE including swallowed steroids (21.2%), diet restriction (6.1%) or combined therapy (18.2%). Nineteen (57.6%) were on PPI. Seven (21.2%) were not on medical therapy. The most common procedural complication was pain (n Z 7, 14.9%). Of those with pain, 6 received reassurance without sequel. One patient (2.1%) was admitted for observation. There were no perforations or other urgent evaluations as a result of esophageal dilation in this population. Conclusions: Dilation for management of dysphagia in EoE can be performed safely in children. Post procedural pain was common (19.4%) in the setting of resultant mucosal split from esophageal dilation.1 M.E. Bohm, J.E. Richter. Review article: oesophageal dilation in adults with eosinophilic oesophagitis. Aliment Pharmacol Ther, 33 (2011), 748-757.
www.giejournal.org
Sa1663 Characterization of Dysphagia Associated Eosinophilic Esophagitis (EoE) in Children With & Without Food Impaction Thirumazhisai S. Gunasekaran*1,2, Alan Schwartz2, James Berman2,3, Vaishali Bothra1, Mohamad Hatahet1, Irfan H. Siddiqui1, Vijayalakshmi Kory1 1 Advocate Lutheran General Childrens Hospital, Park Ridge, IL; 2Dept of Pediatrics, University of Illinois, Chicago, IL; 3Pediatrics, Loyola University Medical School, Maywood, IL EoE in children has been associated with a variety of symptoms, Consensus-2011 statement classifies patients into 4 groups based on predominant symptom, EoEdysphagia( D), abdominal pain (AP), GERD and failure to thrive. In a previous presentation we showed the outcome of EoE- AP is suboptimal compared to EoE- D. Now within the EoE- D group we looked to see if there is a difference in patients presenting with and without food impaction. Aim: Compare clinical features, endoscopy+ biopsy, and outcomes of EoE - D patients presenting with and without food impaction.: In this retrospective study, patients with EoE-D seen between 9/ 2005 and 7/2012 were stratified into; Group I, with food impaction and Group II, without food impaction. Physical findings, CBC, CMP, esophagram, EGD+ biopsies of the duodenum, antrum, distal and mid esophagus were captured. Diagnosis of EoE was made as per the consensus guidelines. Treatments included dietary modification and topical or oral steroids, alone or in combination. Clinical outcome was measured as improved, worsened or same. Results: Patients; Gr I 18, Gr II 18, mean age 14.77 , 14.83. Following were similar in both groups; regurgitation ( 5%), heart burn ( 22%), physical examination, CBC and CMP . Following were different in Gr I and II respectively; male predominance ( 72%, 78 %), abdominal pain: 5 and 28%, vomiting: 11 and 5%, early satiety: 5 and 0%. Esophagram; Gr I; 6 done and 3 had eso narrowing, Gr II: 6 done and 4 had narrowing . EGD ( Gr I and II) ; edema 33%, 44%; rings 22%, 16%, exudates both 44%, furrows 66%, 55%. There were no statistical difference with in the two groups. Biopsy; Gr I and II; mean peak esosinophil count 59.33 , and 40.11, eos.microabscess 22%, 39%, basal epithelial hyperplasia 50%, 33 %, spongiosis both 16%. All patients with food impaction required endoscopic removal and there were no perforations.Follow up done upto 7.6 years.With treatment Gr I and II had; 55% , 39% symptomatic improvement. 6/18 patients in Gr I and 7/18 in Gr II had a follow up EGD and the mean peak eos count was 54.3 and 30.1 respectively. 2/ 18 patients in Gr I had recurrence of food impaction and none in Gr II developed food impaction. Conclusion: By definition, both groups had dysphagia as the predominant symptom. There were no significant differences in the clinical features, endoscopic findings and outcome of the two groups. However, the peak eosinophil count was higher in the food impaction group, at presentation and follow up, suggesting more inflammation in this group. On follow up minority of food impaction group had recurrence of food impaction. The EoE-D food impaction group, with its increased inflammation and resulting in secondary dysmotility, may require more aggressive therapy. More prospective studies with larger numbers are needed to validate these data.
Sa1664 The First Case Report of Esoflip for Dilation of a Pediatric Esophageal Stricture Richard A. Lirio*1, Pradeep Nazarey2, John O’Dea3, Jenifer R. Lightdale1 1 Pediatric Gastroenterology/Hepatology/Nutrition, UMASS Memorial Children’s Medical Center, Worcester, MA; 2Pediatric Surgery, UMASS Memorial Children’s Medical Center, Worcester, MA; 3Crospon, Dangan, Ireland Treatment of benign strictures associated with eosinophilic esophagitis (EoE) in children typically involves balloon dilation with fluoroscopy as an effective, but imprecise means of widening the esophageal luminal diameter that requires radiation exposure. EsoFLIP is a novel technology that integrates multiple adjacent impedence planimetry electrodes into a dilation balloon as a means of precisely targeting dilation diameters without need for fluoroscopy. Aim: To test the technical feasibility of EsoFLIP for dilation of a benign stricture associated with EoE in a pediatric patient. Methods: We obtained informed consent/assent to use the EsoFLIP ES-320 dilation balloon (Crospen, Galway, Ireland) to evaluate and treat a 17 year old male with a history of food impactions and a significant stricture on barium swallow (Fig 1a). We compared real-time measurements pre- and post- dilation obtained using EsoFlip with traditional fluoroscopic images using Omnipaque contrast solution (300mgI/ml) (NDC 0407-1413-61, GE Healthcare). The EsoFLIP balloon was inflated using 20 ml at a gentle inflation rate of 20ml/min. The balloon was introduced under endoscopic visualization, and approximately centered within the narrowed region of the esophagus. The endoscope was then retracted to remain in the upper esophagus proximal to the balloon for the duration of the procedure. Our goals were to obtain precise measures of (1) normal esophageal lumen; (2) the waist of the stricture pre-dilation, and (3) the degree of recoil post-dilation. Dilation success was defined as achievement post-recoil of a target diameter. Results: The EsoFLIP balloon dilator was safely deployed in our patient without complication. The proximal esophagus was measured using EsoFLIP to be approximately 18 mm in diameter, while the waist was approximately 10.2 mm in diameter. (Fig 1a) Dilation was targeted to a lumen opening diameter of 15 mm, and was achieved by injecting 29 ml of fluid until the waist was measured to be 15 mm. (Fig 1b) After deflation of the balloon to 20 ml volume, we assessed the degree of recoil and found a 17%
Volume 81, No. 5S : 2015 GASTROINTESTINAL ENDOSCOPY AB299