Management Of Eosinophilic Esophagitis Research Articles

Efficacy and Safety of Monoclonal Antibodies for the Treatment of Eosinophilic Esophagitis: A Systematic Review and Meta-Analysis of Randomized Controlled Trials.

Monoclonal antibodies (MAbs) have clinical benefits for treating several atopic diseases. However, consensus on its use for eosinophilic esophagitis (EoE) is lacking. The present meta-analysis aimed to compare the efficacy and safety of MAbs versus placebo for treating EoE. We searched PubMed, Embase, and Cochrane Library for randomized controlled trials (RCTs). The primary outcomes were changes in peak esophageal eosinophils count/high power field (HPF) and mean esophageal eosinophils count/HPF. The secondary outcomes were changes in the EoE-Histology Scoring System (EoE-HSS), Endoscopic Reference Score (EREFS), dysphagia score, and adverse events (AEs). We compared binary outcomes using risk ratio (RR) and continuous outcomes using mean difference (MD) or standardized mean difference (SMD), with 95% confidence interval (CI). Considering the diversity of mechanistic properties of MAbs, a pre-specified subgroup analysis by MAb mechanism of action was performed for all outcomes, provided that at least two studies were in each subgroup. Heterogeneity was assessed using Cochran's Q test and I2 statistics. 6 RCTs were included (533 patients). Compared to placebo, MAbs led to a significant reduction in peak esophageal eosinophils count/HPF (MD -0.78; CI 95% -0.87, -0.6801) and mean esophageal eosinophils count/HPF (SMD-0.79; CI 95% -1.5, -0.08). Moreover, MAbs significantly reduced EoE-HSS scores (grade score: SMD-9.31; 95% CI -13.95, -4.6701; stage score: SMD -10.18; 95% CI -15.06, -5.31), EREFS (SMD-5.95; CI 95% -9.19, -2.71) and dysphagia score (SMD -1.79; CI 95% -3.36, -0.23) without increasing AEs compared to placebo. Among those MAbs whose mechanism of action includes the blockage of the receptor for IL-13 (Dupilumab, QAX576, and RPC4046), the scores of EoE-HSS grade, EoE-HSS stage, EREFS, and dysphagia were significantly reduced, and they presented a similar risk of overall and serious AEs compared to placebo. MAbs seem effective and safe in reducing esophageal eosinophil infiltrate, EoE-HSS score, EREFS score, and dysphagia symptoms in patients with EoE. However, further evidence is needed to establish its place in EoE management.

Evolving strategies: Enhancements in managing eosinophilic esophagitis in pediatric patients.

Eosinophilic esophagitis is a newly recognized disease first described about 50 years ago. The definition, diagnosis, and management have evolved with new published consensus guidelines and newly approved treatment available to pediatricians, enabling a better understanding of this disease and more targeted treatment for patients. We describe the definition, presentation, and diagnosis of eosinophilic esophagitis including management, challenges, and future directions in children. The definition, diagnosis, and management of eosinophilic esophagitis have evolved over the last 50 years. Consensus guidelines and newly approved biologic treatment have enabled pediatricians to better understand this disease and allow for more targeted treatment for patients. We describe the definition, presentation, diagnosis, management, and treatment in addition to the challenges and future directions of eosinophilic esophagitis management in children.

Correction to "Diagnosis and management of eosinophilic esophagitis".

Correction to "Diagnosis and management of eosinophilic esophagitis".

Diagnosis and management of eosinophilic oesophagitis

Diagnosis and management of eosinophilic oesophagitis

Diagnosis and management of eosinophilic esophagitis.

Diagnosis and management of eosinophilic esophagitis.

A Practical Update on Pediatric Eosinophilic Esophagitis.

Eosinophilic esophagitis (EoE) is an emerging atopic disease of unknown etiology limited to the esophagus. The pathogenesis is still understood and is likely characterized by type 2 inflammation. Food allergens are the primary triggers of EoE that stimulate inflammatory cells through an impaired esophageal barrier. In children and adolescents, clinical presentation varies with age and mainly includes food refusal, recurrent vomiting, failure to thrive, abdominal/epigastric pain, dysphagia, and food impaction. Upper-gastrointestinal endoscopy is the gold standard for diagnosing and monitoring EoE. EoE therapy aims to achieve clinical, endoscopic, and histological ("deep") remission; prevent esophageal fibrosis; and improve quality of life. In pediatrics, the cornerstones of therapy are proton pump inhibitors, topical steroids (swallowed fluticasone and viscous budesonide), and food elimination diets. In recent years, much progress has been made in understanding EoE pathogenesis, characterizing the clinical and molecular heterogeneity, and identifying new therapeutic approaches. Notably, clinical, molecular, endoscopic, and histological features reflect and influence the evolution of inflammation over time and the response to currently available treatments. Therefore, different EoE phenotypes and endotypes have recently been recognized. Dupilumab recently was approved by FDA and EMA as the first biological therapy for adolescents (≥12 years) and adults with active EoE, but other biologics are still under consideration. Due to its chronic course, EoE management requires long-term therapy, a multidisciplinary approach, and regular follow-ups.

Diagnostic role of fractional exhaled nitric oxide in pediatric eosinophilic esophagitis, relationship with gastric and duodenal eosinophils

Eosinophilic esophagitis (EoE) is an eosinophilic-predominant inflammation of the esophagus diagnosed by upper endoscopy and biopsies. A non-invasive and cost-effective alternative for management of EoE is being researched. Previous studies assessing utility of fractional exhaled nitric oxide (FeNO) in EoE were low powered. None investigated the contribution of eosinophilic inflammation of the stomach and duodenum to FeNO. To assess the utility of FeNO as a non-invasive biomarker of esophageal eosinophilic inflammation for monitoring disease activity. Patients aged 6-21 years undergoing scheduled upper endoscopy with biopsy for suspected EoE were recruited in our observational study. Patients on steroids and with persistent asthma requiring daily controller medication were excluded. FeNO measurements were obtained in duplicate using a chemiluminescence nitric oxide analyzer (NIOX MINO, Aerocrine, Inc.; Stockholm, Sweden) prior to endoscopy. Based on the esophageal peak eosinophil count (PEC)/high power field on biopsy, patients were classified as EoE (PEC ≥ 15) or control (PEC ≤ 14). Mean FeNO levels were correlated with presence or absence of EoE, eosinophil counts on esophageal biopsy, and abnormal downstream eosinophilia in the stomach (PEC ≥ 10) and duodenum (PEC ≥ 20). Wilcoxon rank-sum test, Spearman correlation, and logistic regression were used for analysis. P value < 0.05 was considered significant. We recruited a total of 134 patients, of which 45 were diagnosed with EoE by histopathology. The median interquartile range FeNO level was 17 parts per billion (11-37, range: 7-81) in the EoE group and 12 parts per billion (8-19, range: 5-71) in the control group. After adjusting for atopic diseases, EoE patients had significantly higher FeNO levels as compared to patients without EoE (Z = 3.33, P < 0.001). A weak yet statistically significant positive association was found between the number of esophageal eosinophils and FeNO levels (r = 0.30, P < 0.005). On subgroup analysis within the EoE cohort, higher FeNO levels were noted in patients with abnormal gastric (n = 23, 18 vs 15) and duodenal eosinophilia (n = 28, 21 vs 14); however, the difference was not statistically significant. After ruling out atopy as possible confounder, we found significantly higher FeNO levels in the EoE cohort than in the control group.

Sex Differences in Clinical Presentation and Management in Eosinophilic Esophagitis

Background: Eosinophilic esophagitis (EoE) is a male predominant disease, typically presenting with dysphagia. Our goal was to investigate sex differences in clinical presentation and management of EoE. Methods: We performed a retrospective cross-sectional review of 489 EoE patients seen at NewYork Presbyterian Weill Cornell from August 2015 to August 2019. Charts were queried for age at diagnosis, symptoms at presentation, endoscopic findings, need for dilations, and medical therapy. Student t and χ2 tests were implemented to compare outcome variables of the 2 independent groups (males vs females) and logistic regressions for invariable and multivariable analyses. Results: 489 EoE patients (226 Female [F] [46.2%], 263 Male [M] [53.8%]) were reviewed. Males were more likely to present with food impaction (92 [35.8%] vs 44 [19.7%], M vs F, P &lt; .001), have a fibrostenotic phenotype on initial endoscopy (140 [54.1%] vs 98 [45.0%], M vs F, P = .043) and undergo dilation (odds ratio [OR] = 1.985, 95% confidence interval [CI] = 1.209-3.328, P &lt; .01). Female patients were more likely to have atopic disease (153 [67.6%] vs 153 [58.8%], F vs M, P = .044) and a reported normal index endoscopy (79 [36.2%] vs 69 [26.6%], F vs M, P = .026). Conclusion: This large retrospective review highlights clinically important differences in presentation between sexes. Increasing awareness of these differences, especially history of atopic disease, impaction, and the need for dilation, can help clinicians better identify EoE in female patients and therefore, guide initial therapy. The mechanistic underpinnings of these discrepancies are not evident from this data and will require future studies.

Management of suspected and known eosinophilic esophagitis-anationwide survey in Austria.

Eosinophilic esophagitis (EoE) is achronic immune-mediated disease of the esophagus with increasing incidence and dysphagia as the main symptom. The management of suspected or known EoE by Austrian endoscopists has not been investigated yet. Aweb-based survey with 13questions about the management of EoE was sent to endoscopists via the Austrian Society of Gastroenterology and Hepatology (ÖGGH). Atotal of 222 endoscopists (74% gastroenterologists, 23% surgeons, and 2% pediatricians; 68% working in ahospital) from all 9states participated. In patients with dysphagia but anormal appearing esophagus, 85% of respondents reported always taking biopsies; however, surgeons were less likely to obtain biopsies compared to gastroenterologists ("always" 69% vs. 90%, "sometimes" 29% vs. 10%, "never" 2% vs. 0%, p < 0.001). The approved budesonide orodispersible tablet is the preferred first-line drug used in EoE, ahead of proton pump inhibitors (PPI). Only 65% of participants monitor the patients by endoscopy and histology after 12weeks of induction therapy, 26% do not continue maintenance therapy, and 22% monitor patients only when symptomatic. The vast majority of Austrian endoscopists adhere to the European and US guidelines in cases of suspected EoE. In contrast, despite the chronic disease course, asignificant percentage of providers indicate not to use maintenance therapy and monitor the patients routinely.

Eosinophilic esophagitis in children: Experience in diagnosis, clinical observation in a multidisciplinary hospital

This study presented the characteristics of seven patients with eosinophilic esophagitis from age 1 year and 2 months to age 17 years and 4 months. The follow-up duration ranged from 1 to 7.5 years.&#x0D; Disease onset was observed at different ages: aged 2 years (n=6) and 2 months (n=1). The period between the occurrences of the first symptom to diagnosis ranged from 3 months to 9 years. In one patient, the symptoms were associated with cows milk allergy, whereas the cause was not identified in other cases. Allergic diseases (i.e., atopic dermatitis, allergic rhinitis, and asthma) were observed in six patients.&#x0D; Treatment was provided according to the clinical guidelines. Six patients were prescribed topical steroids (budesonide) and an empirical elimination diet. One patient was prescribed only with an empirical elimination diet due to the steroid phobia of the parents. However, the ineffectiveness of the diet was the basis for topical steroid prescription. During the follow-up, a relapse was observed in two patients who required repeated treatments.&#x0D; A clinical case of eosinophilic esophagitis in a 6-year-old child, with 7.5 years of follow-up, was described. According to the anamnesis, the patient visited a gastroenterologist 4 years after the onset of dysphagia symptoms. Endoscopy revealed cicatricial stenosis of the upper third of the esophagus (grades 23). A morphological study of the esophageal mucosa, which was performed after repeated endoscopic bougienage and a 5-month course of antisecretory therapy was deemed ineffective, revealed massive eosinophilic infiltration. Eosinophilic esophagitis was confirmed based on the anamnesis, clinical symptoms, and endoscopic and morphological data. An elimination diet and topical corticosteroids (budesonide) were prescribed. Following the treatment, the patient showed significant improvements. Subsequently, during the follow-up, a relapse of eosinophilic esophagitis was diagnosed twice (with an interval of 2.3 and 2.5 years), which required topical steroids (case 1) and proton pump inhibitors (case 2).&#x0D; This paper highlights the importance of a multidisciplinary approach, involving an allergist-immunologist, pediatrician, gastroenterologist, endoscopist, and pathologist, in the management of eosinophilic esophagitis in children.

Salivary microRNAs in pediatric eosinophilic esophagitis

Background: Diagnosis and management of eosinophilic esophagitis (EoE) occur via esophagogastroduodenoscopy with tissue biopsy. Objective: We sought to determine if salivary microribonucleic acid (miRNA) levels could differentiate children with EoE, serving as a noninvasive biomarker. Methods: Saliva was collected from children undergoing esophagogastroduodenoscopy (N = 291). miRNA analysis was conducted on 150 samples: EoE (n = 50), no pathologic alteration (n = 100). RNA was quantified with high throughput sequencing and aligned to build hg38 of the human genome using sequencing and alignment software. Quantile normalized levels of robustly expressed miRNAs (raw counts > 10 in 10% of samples) were compared across EoE and non-EoE groups with Wilcoxon rank sum testing. miRNA biomarker candidates were selected based on variable importance projection (VIP) scoring with partial least squared discriminant analysis (VIP > 1.5). Ability of these miRNAs to differentiate EoE status was assessed via logistic regression. Putative biologic targets for the miRNA candidates were determined in miRNA pathway analysis software. Results: Of the 56 salivary miRNAs reliably detected, miR-205-5p displayed the largest difference between EoE and non-EoE groups (V = 1623, adjusted p = 0.029). Six miRNAs (miR-26b-5p, miR-27b-3p, Let-7i-5p, miR-142-5p, miR-30a-5p, miR-205-5p) displayed elevated VIP scores (>1.5) and were able to differentiate EoE samples on logistic regression analysis with 70% sensitivity and 68% specificity. These six miRNAs demonstrated significant enrichment for gene targets involved in valine, leucine, and isoleucine biosynthesis (p = 0.0012), 2-oxycarboxylic acid metabolism (p = 0.043), and steroid hormone biosynthesis (p = 0.048). Conclusions: Salivary miRNAs represent a noninvasive, biologically relevant measure that may aid disease monitoring of EoE.

Comparison of viscous budesonide and fluticasone in the treatment of patients with eosinophilic esophagitis: a systematic review and meta-analysis.

Steroids are an important pharmacologic treatment in patients with eosinophilic esophagitis (EoE). Fluticasone and budesonide are the 2 main steroid medications used in EOE treatment, but current United States (US) guidelines do not recommend one agent over the other. In this study, we conducted a meta-analysis to compare important patient outcomes when both agents are used. A comprehensive search of MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, and Scopus was performed from each database's inception to March 29th, 2023. Two independent reviewers systematically identified trials that compared the effect of budesonide vs. fluticasone in the management of EoE. A meta-analysis was performed using a fixed-effects model. The primary outcome was the histologic response (defined as an eosinophil count <15 per high-power field) which reflects the response to treatment. Three studies met our inclusion criteria and were included in the analysis, with a total of 272 patients. All studies were carried out in the US and 1 was a randomized controlled trial. Our meta-analysis showed no statistically significant difference with the use of budesonide compared to fluticasone in achieving a histologic response (odds ratio 1.29, 95% confidence interval 0.77-2.14; P=0.34; I2=0%). Our systematic review and meta-analysis indicated no difference between budesonide and fluticasone in achieving a histologic response in patients with EoE.

Management of Eosinophilic Esophagitis in Pediatric Patients Undergoing Food Allergen Oral Immunotherapy

Oral immunotherapy (OIT) is a promising treatment for food allergy, however, some patients cannot initiate or continue OIT if they develop eosinophilic esophagitis (EoE). Here we present the management and outcomes of pediatric patients with EoE and being treated with concurrent OIT for IgE-mediated food allergy.

Cross-reactive food and pollen allergens most commonly involved in oral allergy syndrome in adults with eosinophilic esophagitis

Like other atopic diseases, oral allergy syndrome (OAS) occurs in patients with eosinophilic esophagitis (EoE), yet is underdiagnosed. As food allergies significantly impact management of EoE, we hypothesize that OAS occurs frequently in EoE, secondary to sensitization to multiple seasonal allergens.

Quality Indicators for the Diagnosis and Management of Eosinophilic Esophagitis.

Despite best practice recommendations for managing eosinophilic esophagitis (EoE), variation in care exists. We used established methodology for quality indicator (QI) development to identify metrics to define quality for the treatment of EoE. Among 29 proposed QI statements, nine (31%) were adopted as highly valid across all categories. Two (22%) of these statements were identified as having existing or suspected quality gaps. We identified highly valid EoE QIs for adult gastroenterologists which can be used for quality improvement with resulting benefits for patient outcomes.

A CASE SERIES OF EOSINOPHILIC ESOPHAGITIS MANAGEMENT IN PEDIATRIC PATIENTS UNDERGOING FOOD ALLERGEN ORAL IMMUNOTHERAPY

<h3>Introduction</h3> Oral immunotherapy (OIT) is a promising treatment for food allergy and can significantly improve patients' quality of life. Eosinophilic esophagitis (EoE) is a known complication of OIT and is presently a contraindication for initiating OIT. We present the management and outcomes of a series of patients with EoE and concurrent treatment with OIT. <h3>Methods</h3> An IRB-approved retrospective chart review was conducted of pediatric patients within the multidisciplinary EoE clinic at our institution (from January 2004 to May 2022). Patients with a diagnosis biopsy-proven EoE and food allergy undergoing OIT were included in the analysis to create the largest case series of its type. <h3>Results</h3> Eleven patients aged 7-17 who were treated with OIT and underwent at least 2 esophagogastroduodenoscopies (EGD) were reviewed. Three patients were diagnosed with EoE prior to initiation of OIT, and the other 8 developed EoE after initiation of OIT. OIT was discontinued in 7 of 11 patients for management of EoE, in addition to treatment with proton pump inhibitors, topical corticosteroid, and/or food elimination diets. Four patients were able to continue OIT with improvement of symptoms and resolution noted on EGD. <h3>Conclusion</h3> The treatment of EoE in patients undergoing OIT requires shared decision-making with the patient/family, active OIT management, and close monitoring of treatment response involving allergists and gastroenterologists. The development of EoE does not always necessitate OIT discontinuation. This case series shows that with close monitoring and follow-up, a subset of patients with EoE can continue OIT safely and successfully.

S2329 Iatrogenic Cushing’s Syndrome in Eosinophilic Esophagitis: A Rare Complication of Swallowed Topical Corticosteroids

Introduction: Topical corticosteroids (TCS) are a first-line treatment for eosinophilic esophagitis (EoE), effective at inducing and maintaining disease remission and well-tolerated with uncommon medication-related adverse events. Despite the theoretical risk of adrenal suppression (AS) with prolonged TCS use, data supporting clinically significant adrenal insufficiency in EoE are lacking and the risk of this rare complication is thought to be low. We present a case of iatrogenic Cushing’s syndrome associated with chronic TCS therapy in EoE and an opportunity for steroid-sparing treatment. Case Description/Methods: A 27-year-old woman with a 7-year history of EoE refractory to proton pump inhibitor, 6-food elimination diet, and swallowed fluticasone (FP) achieved disease remission with high-dose oral viscous budesonide (OVB) 4mg. Rapid recurrence of dysphagia, endoscopic findings, and esophageal eosinophilia occurred with lower OVB doses. After FP use for 5 years and transitioning to OVB for 18 months, she developed cushingoid features including prominent pathologic striae on the abdomen, breasts, and thighs, facial rounding, supraclavicular fullness, central obesity, and a dorsocervical hump. Given known exposure to exogenous steroids, features consistent with iatrogenic Cushing’s syndrome, and assumed hypothalamic-pituitary-adrenal axis (HPAA) suppression, the patient began a taper of OVB and steroid-sparing treatment was initiated with dupilumab 300mg weekly. After tapering OVB to 2mg daily over 2 months, assessment (ACTH, morning cortisol, 24-hour urine cortisol) was normal, consistent with HPAA recovery (Figure). Discussion: Topical steroids such as OVB are commonly used and recommended for long-term management of EoE with rare reports of adrenal insufficiency. As data supporting biochemical AS with TCS use in EoE is limited to observational studies with heterogenous testing for AI and lack of symptom assessment, the risk of clinically relevant AS is likely low. However, our case demonstrates that despite the favorable pharmacokinetics, systemic effects of TCS may be understated, particularly with high compliance and prolonged use of high daily doses. Clinicians should counsel patients on the non-negligible risk of AS when prescribing TCS for EoE, and consider assessment of the adrenal axis or use of steroid-sparing agents in those reliant on chronic TCS for disease control.Figure 1.: Endoscopic evidence of (B) active disease on FP (B) disease remission on OVB 4mg daily; (C) Cushingoid features of abdominal striae and dorsocervical hump.

Subtyping of Eosinophilic Esophagitis Based on Disease Presentation in a pediatric Cohort.

Eosinophilic esophagitis (EoE) is an immune-mediated inflammatory disease characterized by eosinophilic infiltration of esophageal tissue. Subtyping of EoE patients could be useful in predicting therapeutic response. We propose clinical subtypes, apply them to our pediatric EoE population retrospectively, and assess therapy choices and remission at one year. A retrospective chart review of pediatric patients diagnosed with EoE was conducted. Patients were grouped into proposed subtypes (severe, allergic, fibrostenotic, inflammatory, unclassified) based on presenting characteristics. The primary outcome was histologic remission, which was defined &lt;15 eosinophils/high-powered-field (hpf) at the closest visit 1 year postdiagnosis. Subtyping was possible in 242 of 256 patients and follow-up histological data were available in 75 subjects. The majority had an overlap in phenotype with 17% severe, 77% allergic, 15% fibrostenotic, 60% inflammatory, and 5% unclassified, whereas 45% of the cohort were assigned to a unique subtype. At 1 year, 43/75 (57%) of patients achieved histologic remission, with an overall average decrease of 33 (IQR -47, -12) eosinophils/hpf across the entire cohort. There was no difference in remission rates among subtypes. First-line therapy review revealed higher rates of proton pump inhibitor (PPI) ± topical steroids utilization in severe patients, while topical steroids were prescribed preferentially over dietary therapy in the fibrostenotic subtype. There were no observed differences in remission rates at 1 year among clinically defined subtypes of EoE, although this could be attributed to overlapping subtypes. Most patients responded well to medical therapy. Larger scale prospective studies designed to subtype patients and protocolize treatment may help personalize the approach to EoE management.

Comparing Eosinophilic Esophagitis in a Black and Non-Black Pediatric Cohort.

To compare presenting symptoms, comorbidities, disease, and treatment characteristics of a black pediatric eosinophilic esophagitis (EoE) group to a non-black pediatric EoE group. A retrospective chart review consisting of pediatric patients diagnosed with EoE between the years of 2010 and 2018 at a single urban pediatric hospital system comprising 143 black pediatric patients compared with 142 non-black pediatric patients with similar distribution of age and sex. Both groups were majority male, and the median age of diagnosis between the black and non-black group was 5.1 and 6.7 years old, respectively. Comorbidities more commonly seen in the black group included food allergies, atopic dermatitis, asthma, and allergic rhinitis. Black patients were more likely to present with failure to thrive (FTT)/poor growth, whereas non-black patients were more likely to present with abdominal pain. There was no statistically significant difference between the groups in achieving remission using current therapies. The black group had higher rates of nonadherence to medical therapies. This is the largest study to date comparing a black versus non-black pediatric EoE population. The black population had more atopic comorbidities and FTT at presentation and had significantly more issues with nonadherence. This new knowledge describing EoE in a minority population will hopefully improve awareness, diagnosis, and management of EoE in this population.

Refractory eosinophilic esophagitis: what to do when the patient has not responded to proton pump inhibitors, steroids and diet.

Management for patients with refractory eosinophilic esophagitis (EoE) remains a clinical challenge. This review aims to define refractory EoE, explore rates and reasons for nonresponse, and discuss the evidence that informs the approach to these patients. Many patients will fail first-line therapies for EoE. Longer duration of therapy can increase response rates, and initial nonresponders may respond to alternative first-line therapies. There are ongoing clinical trials evaluating novel therapeutics that hold promise for the future of EoE management. Increasingly, there is recognition of the contribution of oesophageal hypervigilance, symptom-specific anxiety, abnormal motility and oesophageal remodelling to ongoing clinical symptoms in patients with EoE. For refractory EoE, clinicians should first assess for adherence to treatment, adequate dosing and correct administration. Extending initial trials of therapy or switching to an alternative first-line therapy can increase rates of remission. Patients who are refractory to first-line therapy can consider elemental diets, combination therapy or clinical trials of new therapeutic agents. Patients with histologic remission but ongoing symptoms should be evaluated for fibrostenotic disease with EGD, barium esophagram or the functional luminal imaging probe (FLIP) and should be assessed for the possibility of oesophageal hypervigilance.