Chapters Transcript Video Stuck on Eosinophilic Esophagitis (EoE): Recognizing and Managing Pediatric Esophageal Eosinophilia Yvette Wild, MD, MPH, discusses managing pediatric Esophageal Eosinophilia. Hi there, thanks for having me. I'm going to start sharing my slides. And um it looks good. Looks OK, Maria. OK. Well, again, thank you for the opportunity to be here to present um on eosinophilic esophagitis. And as Maria and Christina had said, I am at UCSF. Um, I run the pediatric eosinophilic GI disease clinic or our EID clinic. We primarily take care of kids with eosinophilic esophagitis, although We do take care of uh eosinophils in the other GI, um, areas as well. But today, I'm going to be presenting on eosinophilic esophagitis, stuck on EOE recognizing and managing pediatric esophageal eosinophilia. Um, before we get too far into the talk, I do have disclosures. Um, in the last 24 months, I have had the following relationships with commercial entities including Sanofi and Regeneron. Um, I'm on their speaker's bureau. Uh, they were not involved and their slides were not involved in the making of this presentation. The CME Committee has mitigated the potential conflict of any interest by requiring changes to my presentation and to make sure it is compliant for CME. Um, so without further ado, some learning objectives from today. At the end of this talk, I hope to, um, have you be able to identify the clinical signs and symptoms concerning for possible eosinophilic esophagitis or EOE. Um, I hope to be able to review the diagnostic criteria for eosinophilic esophagitis, which include both symptoms and endoscopic findings and pathology. Um, we will briefly, uh, discuss the range of treatment options available for treating EOE. And then lastly, um, we will talk about the long-term risk for untreated progressive inflammation and disease of the esophagus. So to begin with, gastrointestinal eosinophils. Do exist along the GI tract. However, it really is dependent on what part of the GI tract that we are discussing in order to understand if this is a normal or abnormal finding. In the esophagus in particular, um, any eosinophil found is an abnormal finding. The esophagus is supposed to have zero eosinophils in its tissue mucosa. However, as you progress along the GI tract, the intestines is exposed to various antigens, digestive enzymes, and there can be eosinophils along the GI tract. In the stomach, anywhere from 2 to 10 can be normal. And again, they grow and grow as you go distal within the GI tract. And in the colon, you can have up to 30 eosinophils in any given microscopic field. Um, that can be defined as an average accepted value of normal. But again, in the, in the esophageal area, 0 is our goal. Eosinophilic esophagitis is a chronic progressive inflammatory response. As the name suggests, it is an eosinophilic predominant inflammation isolated to the esophagus and the esophagus only. It is a type 2 inflammatory response, um, where the eosinophils are brought to the surface, and as As they are brought to the surface, they're responsible for remodeling of the tissue and ultimately fibrosis of that tissue. Fibrosis of the esophageal area can lead to dysphagia or swallowing abnormalities, um, and ultimately stricture formation and food impaction. Um, the entity of eosinophilic esophagitis has been around for 30 or 40 years, but even in this time, um, we have seen a rising increase of prevalence and incidence within pediatrics. This is a study that was isolated to the group, um, at Children's Hospital of Philadelphia. Again, it's already about 20. years old or so, they looked at 14 years of eosinophilic esophagitis incidents and even in the span from 1996 to 2006 in the tri-state area, um, you can see there has been rising. Incidence of eosinophilic esophagitis. This interestingly matches the overall rise in allergies in general. So whether it's asthma, atopic dermatitis, um, there seems to be a trend where we are seeing more and more of atopic diseases, including eosinophilic esophagitis. Um, currently, we estimate the prevalence of EOE in the US about 1 to 700. It seems like there is a male to female ratio of 3 to 1. Um, again, the data currently suggests that, um, the, uh, The EOE findings are predominantly in, in, in white, uh, folks, um, with a mean presentation of 6 to 12 years, um, in children, and there's another, uh, kind of bump in the adult population at around 30 years. Um, but I'll stop here and just say that we have seen in our practice, really any age, any race, any gender. Um, and so for all children, we really have to think about eosinophilic esophagitis in the right context. Um, certainly, eosinophilic esophagitis, um, we see it clustering in families. Um, and again, because it is a relatively new condition, um, we will often diagnose our patients, and then we'll hear later on down the line, oh yeah, you know, my father, my, my mother, my grandfather, you know, had X, Y, Z symptoms. Um, but we certainly hear about these, um, symptoms clustering in families. And eosinophilic esophagitis is an atopic inflammatory response. Um, so it can be more common in patients with other atopic conditions, including, um, atopic dermatitis, um, eczema, and other, um, allergic conditions. Um, in taking into account the symptoms of eosinophilic esophagitis, we can split it into two categories, how children present and how teenagers or adults present. It's easier to start with the adults. Almost all adults and older teenagers present with some sort of dysphagia. They will tell you that food gets stuck or it's hard to swallow, um, when they're eating. They will often have to drink a lot of water to pass food, or they will have to regurgitate it and spit it back up. They may also present with food impactions, um, traditionally in the emergency room, um, or other signs of heartburn or abdominal pain. In contrast, children are a little bit trickier. Um, Their symptoms are, are more non-specific. So they may not present typically with dysphagia. In fact, they may not even know how to describe dysphagia. Instead, children and toddlers may present with just feeding refusal or feeding difficulty. Um, if they choose not to eat, um, they may present with poor weight gain or failure to thrive. Um, they may have vomiting if they're feeling like food is getting stuck, and they may complain of, of non-specific abdominal pain. So with children, the EOE symptomatology is, is tricky, um, and it clearly is going to be one of many differentials that you think about with the picky toddler, which again, there are so many reasons why kids come in with feeding refusal and difficulty. Um, additionally, children are very smart. They develop a lot of adaptive behaviors, which, again, delay diagnosis and, um, delay treatment for possible eosinophilic esophagitis. So this is when your history is going to be incredibly valuable, um, in really understanding how kids eat and if you need to think about eosinophilic esophagitis. For example, many children, um, will drink fluid with meals. They, they They need to drink water to pass food down that tight esophagus. Um, but the only history may they just drink a lot of water with their meals. You may hear of, of, of the toddler or the child that modifies their foods. They prefer purees and liquids, smoothies, small pieces. They may have prolonged chewing times. They sit at the table. They're the last ones at the table, and they sit and they chew and chew and chew essentially until their food is down to a puree consistency. These may be the kids that in general avoid hard textures. Um, or the older kids who cannot swallow pills or tablets. So again, um, a very careful history is going to be essential, um, to, to putting eosinophilic esophagitis on your radar. What we do know is that if symptoms are untreated, their their their condition progresses, their inflammation progresses, and then their symptoms may also change as a result of that, um, of that evolution of, of, of inflammation. Um, the X axis on this chart demonstrates age. There is some controversy over how quickly, uh, children will go through this symptom progression. But again, as discussed, as the toddler, you might just see these non-specific feeding difficulties. As they progress, they may develop vomiting or reflux, maybe some abdominal pain. And then usually, it is the teenage years um where we will see uh true dysphagia and then esophageal stricture or food impaction. But by the time they, they present with a food impaction, you know, it's been there for, for many, many, many years. So as we discussed, clinical symptoms are going to be so important, um, and understanding clinic clinical symptoms, um, over a prolonged period of time, how this affects their growth and nutrition, other atopic conditions, and their own family history are very important. However, that alone does not diagnose eosinophilic esophagitis. Usually, that then uh necessitates a referral to our group where we will proceed with an endoscopy. Um, Endoscopic appearances are very important in understanding the risk and progression of eosinophilic esophagitis. Um, there is the Endoscopic Reference score or the EREFS. We use this in our practice. You'll see this commonly referred to in clinical trials and other medical literature. Um, we'll talk about this briefly. Again, this is more on the GI side, but this is how we describe what we see and we try to describe some uniform score. Um, thirdly, histopathology or our biopsies are going to be, again, the gold standard. Ultimately, Um, seeing and counting eosinophils. Um, in our practice, we take at least 6 esophageal biopsies because eosinophilic esophagitis can be a patchy condition. We will often take biopsies from the top, middle, and bottom of the esophagus. And Anything greater or equal to 15 eosinophils per high-powered field is a diagnosis of eosinophilic esophagitis. Again, we talked about how the esophagus technically should have zero eosinophils. Between 0 to 15, we can see maybe reflux present in that range, but true eosinophilic esophagitis, um, needs greater or equal to 15 eosinophils per high-powered field. Because of the area of overlap in the esophagus with a more common condition like reflux, um, or a more common presentation like reflux, um, oftentimes, Most patients will undergo high dose proton pump inhibition for 8 weeks, again to treat what might be reflux, but if you continue to show signs of greater or equal than 15 eosin levels per high powered field despite Uh, PPI therapy, um, then you are likely somebody that has eosinophilic oesophagitis. And then, of course, there are other GI disorders that may also have eosinophils in the tissue. Um, again, those are not as common, but, um, within our group, we will make sure to exclude those other conditions as well. But if you have the trifecta of clinical symptoms, endoscopic changes, and histopathology, um, and you test positive for all those three, then you have a diagnosis of eosinophilic esophagitis. Um, this is an example of the ERF score. Again, what we're looking for is just visually what we see on endoscopy. So the E stands for edema. Um, looking for any kind of swelling or loss of vascular markings. Grade 0 is a normal esophagus, and grade 1 and 2, you start to see swelling. And again, these are appreciated at a, at a closer view with our scopes. Um, R stands for rings or trachealization. As the disease progresses, there is more and more fibrosis, and you see, um, you can actually see these concentric rings around the esophagus. They almost look like a trachea. Um, and again, we will grade the, the art in anywhere from 0 to 3. The E stands for exudates. Oftentimes, um, eosinophils, again, as they continue to evolve, will cluster in these white plaques along the esophagus. If we see those, then we might give a grade 1 or 2 for the E. F is our furrows. Furrows are, are longitudinal lines through the esophagus that also suggests ongoing inflammation. And we will grade that. And then lastly, stricture is the S. So, yes or no? Is there or is there not an esophageal stricture? And we give the ERF score, which, again, at its highest is a total of 9, we'll, we'll, we'll grade them at the top. Of the esophagus and at the bottom of the esophagus. So, all in all, you can have the highest ERAP score is an 18 if you get a 9 at the top, 9 at the bottom, or a 0 if everything is normal. So, again, this is how we communicate within our group of what we see endoscopically. Um, and then as mentioned, we do take tissue biopsies. We send them to the lab. Um, the, uh, pathologist is looking for specifically numbers of eosinophils, um, in, in the tissue. Um, however, they will often, um, also comment on basal cell hyperplasia, which is suggestive of ongoing inflammation. You might see an abscess at the surface, um, clustering, degranulation, um, and then fibrosis if there is ongoing inflammation and stricture formation. So, again, there's a lot to learn on the histopathology, uh, that, that we, um, value. Um, this is just a, a, a kind of a sign of putting, putting all three things together. Again, the top is a sign as a diagram of, uh, the esophagus, both a side view and then kind of a, a straightforward view of how that esophagus, um, changes as it becomes. More inflamed, more fibrotic, and then, you know, with inflammation and fibrosis, ultimately, it just gets tighter, smaller, um, the contour of the esophagus gets more rugged, and you can imagine how food just does not slide through that esophagus as easily and may actually just get stuck. Um, histology, again, we talked about how normal histology on the left shows a nice healthy mucosa void of any eosinophils. As inflammation progresses, the red eosinophils continue to cluster and to increase. And then the green fibrosis toward the bottom of those histology slides gets thicker and harder and tougher. Um, so, children, again, will often respond very well early in life and early in this disease process to medical and diet therapy. But ultimately, if this disease progresses, um, and oftentimes with our older teenagers and with some of the adults that we might see, um, we're talking more about dilations. Um, this is just a quick slide to look at some of the, um, the mechanism of action. Again, this helps in understanding the treatments that we have to offer. Um, very briefly, T cell inflammation, there are 3 different types, 12, and 3. Type 1 and type 3 are inflammatory responses that we will often see in conditions like inflammatory bowel disease. So you see the key cytokines are, um, are Targets for medications used for inflammatory bowel disease. For eosinophilic esophagitis specifically, this is a type 2 reaction. So this is a very different type of reaction. Again, it's calling upon the eosinophils. The key cytokines are IL 4, IL5, IL-13, and aisle 31. And as you can see, some of the associated diseases include not only EOE but atopic dermatitis, asthma, anaphylaxis, um, Again, more of the um allergic types and um some of the parasitic uh types as, as well and on the type 2 pathway. But IL 45, and 13 have been the focus of many uh uh therapeutic targets. Um, and this is a quick, just overall summary of really kind of the 30,000 ft view of EOE. You know, we haven't quite identified if there are specific genetic abnormalities that can flag EOE, but we do know that it clusters in families. So again, research is ongoing. But we do know that this is a food antigen-driven inflammatory response. Um, and again, food antigens are the primary reason why eosinophils are brought to the surface. There might be Environmental factors and aeroallergens that also can cause a flare or an uptick, but primarily it's a food antigen-driven response. When the eosinophils come to the surface, there is barrier dysfunction, dilated intracellular spaces, um, and, um, inflammation starts to arise both on pathology, but also macroscopically, and we see that with our eyes and our scope. And then ultimately, fibrotic dysmotility, strictures, um, and, um, overall problems swallowing. If left untreated, um, we talked about stricture formation. Again, um, many of, of these older kids will present with long untreated disease, um, and esophageal strictures, as can be seen on these barium swallow studies, you can see why food gets stuck. It just cannot accommodate the same type of, of foods and the same type of nutrition that's needed. Um, ultimately, the food impaction is really why we treat this condition. This is the, the, the dreaded consequence of not treating EOE. Um, Food impaction is when food gets stuck lodged in the esophagus. This is a reason for endoscopic management that is an emergency. Um, these kids will often present to the emergency room, and a delay in removing that food for more than 24 hours is associated with increased risk for esophageal perforation. Um, so, we are very aggressive about, uh, treating for, treating EOE when we can, um, when we are able to, to properly diagnose EOE. Um, so there are lots of different arms for treatment. Um, Intrinsically, the, the, the bottom line is, you know, if food causes this inflammatory response, then possibly eliminating this food will, will help heal the mucosa, and it does. Um, but this is a, a challenging quality of life, uh, treatment option. Um, but the data shows that if If you do eliminate the right food, you can treat this disease, and we have had some success in finding the right foods to eliminate, and our kids go on to um heal their, their esophageal mucosa. The difficulty is that the, um, the labs that we have available for allergy testing, specifically skin prick testing or um specific IgE serum testing, they're not actually answering our question of what foods cause EOE. The tests that we have available um through our allergists are looking specifically for IgE mediated allergic reactions. Um, this is for something like anaphylaxis. Um, however, EOE is not, is a non-IGE mediated food reaction. So, we have at times, um, tried to look for targeted elimination of foods based on allergy testing, but the truth is we're not very good at it because again, we're looking for a non-IgE mediated. Uh, food reaction and the only thing we know to test are IGE tests. So this approach is only effective in up to 45% of, of patients, and I would argue it's even lower in our practice. Um, there, there is a, a, a nice study that looks at just empirically eliminating the top six foods that we know trigger EOE. So this includes dairy, eggs, soy, wheat, peanuts, tree nuts, and fish, shellfish. Um, Again, no testing needed. Just take those all out of the diet. The data shows that 70 to 75% of kids do respond if you take these all out of their diet. Oftentimes, if this is successful in clearing their EOE, we will slowly reintroduce one food at a time and then repeat a scope to see if that one food triggered their EOE. Because oftentimes, they don't need to take all 6 foods out permanently. Um, but upfront, um, this is what we offer if they want a successful empiric elimination diet. Again, it is successful in 70 to 75% of patients, um, but this is where the data lies. And then we know from other kids, and we do have a few younger kids who are on a completely elemental diet. It's all they eat. Um, it's all, you know, oftentimes these are kids that are G tube fed. Um, and they clear up their EOE in 90% of the cases, but as you can imagine, The empiricsix food elimination diet or SVED or the elemental diet, this is a really hard uh treatment option to think of in terms of the long term success, because again, this is a condition that we don't expect kids to outgrow. We have to manage them, but this is something that they will likely have for the rest of their lives. So oftentimes, Patients will ask about food elimination and allergen avoidance, and we discuss all these options, but at the end of the day, this doesn't become a very, uh, Efficient long term solution. Um, so for many, many years, we offered swallowed steroids, um, specifically swallowed fluticasone and swallowed budesonide. Both of these need to be swallowed. Again, not inhaled like they would be for a condition like asthma, but swallowed so that they could coat the esophageal surface. And treat the eosinophilic infiltration, um, that's right at the surface. So, similarly, I tell patients to putting hydrocortisone on an, you know, an eczema rash, um, we are putting budesonide and fluticasone on their EOE. It's about 50% effective in some of the clinical trials. Again, it's much better than, than eliminating, you know, your top six favorite foods, um, because on the swallowed steroids, you can continue to eat the foods that cause the reaction because now you're treating them. But they're not hugely effective, and kids do need to take these swallowed steroids, uh, twice a day, every day. And because they sit on the surface of the esophagus, they're not allowed to eat or drink for 30 minutes after taking their, their dose. And while this Can be effective. Again, the data is not very high, and as kids get older, they often forget they're not compliant. Again, it's hard to remember to do something twice a day every day, and then no food or drink for 30 minutes afterwards. Um, there are times where we go to systemic steroids and not just swallowed steroids, but again, because this is a chronic condition, we do not like to use systemic steroids chronically. So we really use oral or IV steroids only in emergency situations like severe dysphagia if they're inpatient because of their condition or if they've experienced severe weight loss, and then we try to get them off these systemic steroids as soon as possible. And then more recently, um, we have had the first biologic agent, um, that has, has been approved of for the treatment of eosinophilic esophagitis. So, in Um, May 2020, um, we started, uh, we, we joined a phase three clinical trial looking at dupilumab, which is an anti-IL4 and IL-13 agent. Again, in thinking about the mechanism of action, these were two of the major cytokines that both cause eosinophilic infiltration and also tissue remodeling. Um. In all, uh, the, the, the study recruited about 60 children. We had 3, I believe, from our practice join the study. Um, and, um, it was a very successful study. Um, and the pediatric study took a few years, but in May of 2022, dupilumab became FDA approved, um, for eosinophilic esophagitis in patients 12 and older. And then, um, last year in January 2024, dupilumab became FDA approved now for children, um, 1 year of age and older and greater or equal to 15 kg. So we've been very fortunate and excited to have yet another option to offer families. Um, it is an injectable medicine, and so families have to understand that it is something that they will have to, um, inject at home, um, but it's been very effective in treating eosinophilic esophagitis, especially in kids who Cannot or don't want to do the dietary elimination, um, cannot or don't want to, or are refractory to the steroid, um, option. It's nice to have yet another option. Um, just a quick note, dupilumab has been indicated for other atopic conditions like, um, atopic dermatitis and asthma, um, for many, many years prior to its indication in eosinophilic esophagitis. Um, so, it's actually of little surprise that it works in eosinophilic esophagitis since again, a lot of the atopic mechanisms are very similar. Um, the actual trial itself, again, as, as I said, about 61 subjects in the pediatric trial were recruited. Um, there was a Part A 16-week placebo controlled treatment period where um it was a 1 to 1 randomization of children into either the dupilumab arm or the placebo arm. And then, um, a scope was performed at the 16-week mark to look for any changes and hopefully improvement. Um, and then after this, there was a 36 week extended active treatment period where the dupilumab treatment arm stayed on dupilumab, and those children who were in the placebo arm were then allowed to also receive dupilumab. And so for the last 36 weeks, all children in the study received dupilumab and um and then a final endoscopy was performed at the 36 week mark. All in all, this whole study lasted 52 weeks or 1 year. Um, the, uh, The table on the right is just a table to look at the two different arms, the dupilumab and the placebo arm. Um, essentially, this is just to show that the arms were relatively, uh, the, the two categories were relatively similar in who they were, um, how they started, what medications they were using prior to the study, um, how many eosinophils were found, the ERF score, um, and their mean weight for age percentiles, their kind of overall nutritional status. Um, and so, as, as, as described, um, at week 16, there was an endoscopy performed, um, to look at the end of the first phase of the study. And the children, um, on the dupilumab injection, 81% achieved histologic remission. Um, this was defined as less than 6 eosinophils per high-powered field, so it was a pretty strict cutoff because again, usually in clinical medicine, we use 15 or less eosinophils, but 81% of children Were found to have histologic remission versus 3% on the control group. And then again, after the full year when all children were then exposed to dupilumab, again, 78% and 67% of children were able to show histologic remission. So now, this isn't yet another option that we offer to our patients. Um, we tell them that dupilumab is um approved of for children, again, greater or equal to 1 year of age and greater or equal to 15 kg. We do, um, base the dose. On their weight. Um, of note, this is a slightly more frequent dose than other conditions for dupilumab like atopic dermatitis. So if they're already on dupilumab for other reasons, um, we will often increase their dose and make it appropriate for eosinophilic esophagitis. And there are some pros and cons, you know, of dupilumab or just the injection itself, but ultimately we've had a lot of success and most families are willing to undergo either an injection every week or every other week, and again, not have to do the swallowed steroids twice a day and not have to restrict their, their diet. Um, we have had a lot of success treating eosinophilic esophagitis, but every once in a while, we'll see a, a, a child come in who again has been undiagnosed for years, if not, um, over a decade, and um we do have to dilate. Um, I think in general, there is kind of a fear of perforation and a, and a fear of dilation, but there's actually very low reported perforation rates in the literature. So, I mean, we, we dilate. Need to. The only problem is really you're just, you're just stretching and aggravating and breaking the scar tissue. So, oftentimes, within a year or two, again, if not adequately treated, the, the, the stricture will reform and the dysphagia will recur. And unfortunately, in, in a lot of adults, this is just what they do. This is how they treat their, their, their disease. They just get dilated every couple of years. Um. And again, long, long-standing strictures may be non-responsive to traditional treatment, um, even though again, our pediatric experience is positive, and we really do minimal dilations because we're very aggressive about treating with medications or dietary therapy. Um, and this is just, you know, just to show how the times have changed. These are the 2025 American Gastroenterology Association guidelines. Um, again, in, in kind of guiding other gastroenterologists on, on how to approach eosinophilic esophagitis, um, there is an effort, you know, between shared decision making and dietary eliminations. But the pharmacologic therapy is, is, um, has, has changed and been updated now to include dupilumab. And again, we talked about proton pump inhibitors and swallow topical steroids, but dupilumab is kind of a, a new, the new kid on, on, on the block. Um, and again, this is the adult guidelines, so they, they, um, uh, oh, actually, they, they do put the, the pediatric dosing down below. But, um, it's exciting to see more and more options become available for our patients over the years. And then lastly, I just wanted to touch upon, um, some kind of new advances. Um, we talked about some of the new therapeutic advances. Um, but even in diagnostic advances, you know, we are always looking to do things better and, uh, more safely for children. Um, unfortunately, many of our kids with eosinophilic esophagitis, they will need, um, Repeat and frequent endoscopies. These endoscopies traditionally, um, are done under general anesthesia. And while it's a quick endoscopy, again, there are children who cannot undergo general anesthesia or at high risk for anesthesia-related complications, or just families who really don't want their kids to be scoped multiple times a year as, as we're changing their diet or changing their therapy or trying to find a new solution. Um, so many years ago, Um, some folks up in Denver, um, paired with their, uh, ENT colleagues, um, and decided, well, if, you know, our ENT colleagues can go through the nose, um, to look at adenoids and tonsils, you know, on an unsedated patient. Um, maybe we can join in with them and, and push the scope a little bit further. I mean, we're already down at, at, at the back of, of, of, of the throat. Maybe we can actually look at the vocal cords and then enter the esophagus, and then we can actually screen the esophagus and get biopsies. So, the unsedated transnasal endoscopy um has become popular um in the last few years. And again, uh, this is when a scope will enter the nose of an unsedated, awake patient. Um, and go through the nasal cavity, down the back of the throat, um, into the esophagus, um, into the stomach even, but can actually do much of what we do with a very small scope and on the awake patient. Because of, of the lack of anesthesia, um, the time from admission to discharge is, is greatly reduced. Um, you come in, you get your scope, and then you take the scope out and you just walk out the door. So, um, studies have shown a 1-hour average time for admission and discharge versus 4 hours with our traditional general anesthesia endoscopy. Um, it is 1/3 the cost of a sedated endoscopy for our families. Um, and then preparation is also much easier. 2 hours without eating versus 8 hours without eating for general anesthesia. So this has become something that has been, um, very, uh, Popularized and patients are asking for this. And so we too have been asking for this, and we're very excited to announce that um as of like two weeks ago, we have the equipment to do transnasal endoscopy. Uh, we had a training session two weeks ago with our techs and our nurses. And then the bottom right is me performing our first transnasal endoscopy on one of my colleagues, Dr. Shelly Chodori, who's also one of our EOC our, our EOE docs. Um, allowed me to scope her. Um, we do provide some, um, uh, nasal lidocaine, um, in the nose and the back of the throat to kind of numb the area where the scope goes. Um, as the scope gets closer to the esophagus, we have The patient swallow and that helps to drag the scope into the esophagus. Um, she did this procedure kind of staring right at me. Um, for children though, we, we, uh, we also do provide these virtual reality. Goggles. So, if they want to just watch something else and just zone out and, and not pay attention to the scope itself, it's probably for the best. So, this is a very exciting advancement. We're hoping to actually start performing this on our patients in December. Um, Right now, you know, we are trying to be very selective over patients who will qualify for this. Obviously, they need to have some Ability to understand the procedure, to be still, um, and kind of maturity in accepting this procedure. It's not comfortable, but it's also, you know, should not be painful. So right now, we're looking for kids really 10 and older, um, mostly who have esophageal disease. Although, again, my hope is as we become more, um, Uh, adapt or adept at performing this procedure, we'll be able to screen for kids with inflammation in the stomach as well. But right now we're focusing on kids who have esophageal disease, um, again, greater than 10 years of age, and we are working closely with, with child life, um, just to make sure that this experience is not traumatic and something that, um, if necessary, they can have this done. Again and again in the future. And again, for those that want to do dietary elimination and food trials, um, where we're asking them to introduce a new food and repeat a scope in 3 months and 1 more new food and repeat a scope, this can be something that at least will take the anesthesia risk out of the picture. Um, so with that, I just have a few take home points. Um, so just to really kind of put out there that EOE does exist. It is a chronic type 2 inflammatory disease. It is rising in incidence and prevalence. Um, it is a, but it is a chronic condition. So, you know, if it's on your radar, it might be on your radar for a long time. Um, aisle 4, aisle 13 are the kind of two targets that have shown the most success, but there are other mediators of type 2 inflammation like aisle 5. So who knows? There, there may be more in the future, um, more treatment options, um. But at least we kind of know what our focus is with regards to the mechanism of this inflammatory response. Um, clinical history, and again, patients who show up to your office, this is going to be the most important part of starting this, this, this journey, this path, especially thinking about adaptive behaviors in our smaller children. Um, but the full diagnosis requires, again, that that history. Um, plus endoscopy, kind of, again, the visual changes, plus the pathology, the microscopic changes. Um, there are new therapeutic treatments and diagnostic studies. Um, so please refer to us early, um, to have the discussion started. And again, the, the, the, the long term risks of, of not treating, um, are dire. They include stricture and food impactions. Um, and so it's something that we really try hard not to even get into that zone because we really don't want to. Once we start down the road, it's, it's just harder to go backwards. And with that, I just wanted to end with a couple of resources. There are some wonderful resources for children, um, and talking about their condition and their disease and resources for parents, advocacy groups. Um, and I know you will have access to my slides, um, at the end of this presentation. So this will all come to you at some point. And um I am available for any questions, concerns or comments. Created by Related Presenters Yvette Wild MD, MPH Pediatric gastroenterologist View full profile
