Kristle Lee Lynch

INTRODUCTION: Eosinophilic esophagitis (EoE) is a chronic, often progressive, type 2 inflammatory disease characterized by eosinophilic infiltration, and esophageal narrowing and dysfunction. This analysis presents 24-week outcomes from the phase 4 REMODEL trial, evaluating long-term esophageal distensibility in adults with EoE. METHODS: Adult patients with EoE were randomized 2:1 to dupilumab 300 mg once weekly or placebo. Patients were assessed overall and by low (P < 0.05). LSM difference vs placebo in the low DP subgroup was +2.21 mm (95% CI: 0.78, 3.63; nominal P = 0.0024). Overall LSM difference for dupilumab vs placebo was −4.96 (−6.06, −3.85) in Endoscopic Reference Scores, and −0.71 (−0.86, −0.57) and −0.65 (−0.80, −0.51) in EoE histology scoring system grade and stage scores, respectively (all P < 0.0001). No new safety signals were identified. DISCUSSION: Dupilumab significantly improved W24 esophageal distensibility outcomes, with greater improvements in the low baseline DP subgroup compared with the overall population (ClinicalTrials.gov, number NCT06101095).

Eosinophilic oesophagitis is a chronic, immune mediated condition characterised by infiltration of eosinophils across the oesophageal mucosa and progressive oesophageal dysfunction. This specialist review explores the changes in understanding of eosinophilic oesophagitis across epidemiology, pathophysiology, diagnosis, and treatment. It highlights the interplay of genetic susceptibility, early life environmental exposures, and immune responses driven by type 2 helper T cells that underpin epithelial barrier dysfunction and fibrostenotic progression. Current diagnostic strategies rely on endoscopic biopsy, but emerging minimally invasive tests (including the oesophageal string test and transnasal endoscopy) offer promising alternatives for disease monitoring. Therapeutic approaches include dietary elimination, drug treatments (eg, proton pump inhibitors, topical corticosteroids), biologics (particularly dupilumab), and endoscopic dilation for fibrostenotic complications. Evidence from landmark trials and guidelines to support phenotype driven, patient centred management are also reviewed. As eosinophilic oesophagitis prevalence continues to rise globally, recent advances in targeted treatments and diagnostics are redefining long term care.

New medical technology and techniques provide opportunities for better, faster care for patients with esophageal diseases, spanning robotics and minimally invasive techniques, artificial intelligence, medical devices, and digital health that are changing how to diagnose and manage patients with both benign and malignant esophageal diseases. We conducted a concise narrative review of recent advances in esophagology from the perspectives of innovators and physicians alike, with an emphasis on ensuring the environment around successful innovation over the next decade. To our knowledge, this is the first innovation‐oriented review centered on the clinical field of esophagology, focusing on applicable content and knowledge gaps across the several individual domains covered in this review.

Esophagogastric junction outflow obstruction (EGJOO) is a heterogeneous disorder characterized by abnormal esophagogastric junction residual pressures in the setting of intact esophageal body peristalsis. This manometric finding is most clinically relevant in patients with dysphagia and chest pain, and may arise from various mechanisms, including structural processes, catheter positioning artifact, and medications. Rarely, manometric EGJOO is a consequence of abnormal relaxation of the lower esophageal sphincter (LES) akin to achalasia. Thus, it is critical in the evaluation of EGJOO to determine if a true pressure gradient exists across the esophagogastric junction (EGJ) that warrants therapy. There are many unanswered questions in EGJOO diagnosis and management, which are addressed in this review in the context of the use of provocative maneuvers during high‐resolution manometry, complementary and alternate testing, and therapeutic options.

The management of acid-based disorders was transformed in the 1980s with the advent of proton pump inhibitors (PPIs), which target the hydrogen-potassium adenosine triphosphatase (proton pump) of the parietal cell. Potassium-competitive acid blockers (P-CABs), a newer class of medications, act at the same proton pump through a novel mechanism resulting in profound and sustained acid suppression. Although trials in Asian populations over the past decades have highlighted the potential benefit of P-CABs, clinical trials in Western populations have been initiated more recently. These trials evaluated vonoprazan in patients with Helicobacter pylori infection, erosive esophagitis, and heartburn with nonerosive reflux disease and have demonstrated promising results, culminating in US Food and Drug Administration approval for these indications. Adverse event profiles between PPIs and P-CABs appear comparable thus far, although additional long-term data on P-CABs are needed. While navigating the evolving landscape of acid suppression, it is crucial to identify which patients and diseases are poised to derive the most benefit from this emerging therapeutic option. This article seeks to highlight important pharmacologic properties of PPIs and P-CABs, understand the current literature with a focus on clinical trials in Western populations, and explore potential scenarios for integrating P-CABs into therapeutic regimens.

INTRODUCTION: There are limited longitudinal data on the impact of chronic therapy on the natural history of eosinophilic esophagitis (EoE), a chronic allergic disease of the esophagus. The purpose of this study was to evaluate if patients with well-controlled EoE were less likely to develop fibrostenotic complications. METHODS: Subjects were identified from a database of pediatric patients with EoE at the Children's Hospital of Philadelphia started in 2000. Patients were then searched in adult medical records to identify patients who transitioned care. All office visits, emergency department visits, and endoscopic, histologic, and imaging reports were reviewed for the primary outcome of strictures and the secondary outcomes of food impactions and dysphagia. Cox proportional hazard regression was performed for outcomes. RESULTS: One hundred five patients were identified with the mean follow-up of 11.4 ± 4.9 years. 52.3% (n = 55) had a period of histologic disease control defined as ≥2 consecutive endoscopies with histologic remission. These patients were less likely to develop strictures compared with patients who did not have a period of histologic control (HR 0.232; 95% CI 0.084–0.64, P = 0.005). Patients who were diagnosed at younger ages were less likely to develop strictures. Presentation with dysphagia or impaction was associated with higher rate of stricture development. DISCUSSION: In this cohort study with > 10 years of follow-up, children with EoE with a period of histologic disease control and diagnosed at younger ages were less likely to develop esophageal strictures. While this suggests histologic remission is associated with reduction of remodeling complications, additional prospective data with long-term follow-up are needed.

Background: Esophagogastric junction outflow obstruction (EGJOO) is a manometric diagnosis based on Chicago Classification version 4.0 (CC4.0) that requires confirmatory testing for clinical relevancy. However, it is still unclear which patients will respond to therapy. Objectives: To evaluate manometric and clinical predictors of abnormal confirmatory testing for patients with EGJOO. Design: This was a prospective observational study of patients with manometric EGJOO and chest pain or dysphagia who underwent confirmatory testing. Methods: Patients with EGJOO on manometry were enrolled and underwent timed barium esophagram or endoFLIP. A subset of patients was given validated surveys, including Eckardt scores (ES) and PROMIS-10. Results: For patients with a CC4.0 EGJOO diagnosis, abnormal peristalsis (OR = 7.0, 95% CI = 1.01–44.6, p = 0.04) and increases in ES (OR = 2.34 95% CI = 1.13–4.86, p = 0.02) were associated with positive confirmatory testing. Conclusion: Patients with potentially actionable EGJOO were more likely to have an abnormal peristaltic subtype of EGJOO or higher ES.