To the Editor: In the description of their Image in ClinicalMedicine on eosinophilic esophagitis (May 17 issue),1 Hawariand Pasricha note that endoscopic dilation of the esophagealstricture near the gastroesophageal junction was performed beforetreatment with oral fluticasone. The safety and efficacy ofesophageal dilation in patients with eosinophilic esophagitisare still controversial. Straumann et al.2 treated 11 patientswith dilation and reported complete improvement in 6 patientsand partial relief in 4 without relevant complications. However,Shafi et al.3 treated 10 patients with 16 endoscopic dilations,5 of which resulted in free perforation or a deep tear. Therewas a significantly increased risk of esophageal perforationwith dilations, especially among patients with multiple esophagealwebs.3
Endoscopic dilation is helpful but must be attempted with prudencein such patients because of the risk of perforation. A trialwith corticosteroids should be considered before endoscopicdilation, in order to reduce active inflammation and the rateof complications with the procedure.4
Philippe Leclercq, M.D. Audrey Marting, M.D. Pierrette Gast, M.D., Ph.D. Liège University Hospital 4000 Liège, Belgium philleclercq{at}belgacom.net
Straumann A, Spichtin HP, Grize L, Bucher KA, Beglinger C, Simon HU. Natural history of primary eosinophilic esophagitis: a follow-up of 30 adult patients for up to 11.5 years. Gastroenterology 2003;125:1660-1669. [CrossRef][ISI][Medline]
Shafi MA, Eisien GE, Al-Kawas FH, Benjamin SB. Increased risk of esophageal perforation with dilatation in patients with multiple esophageal webs (feline esophagus): a case control study. Gastrointest Endosc 1997;45:56-56. [ISI]
Sgouros SN, Bergele C, Mantides A. Eosinophilic esophagitis in adults: what is the clinical significance? Endoscopy 2006;38:515-520. [CrossRef][ISI][Medline]
The author replies: I agree that dilation in cases of suspectedeosinophilic esophagitis should be carried out with caution.However, there is a difference between empirical dilation ofwebs in patients with chronic dysphagia and dilation of high-gradefibrotic strictures. In the case presented, the patient hada high-grade stricture at the gastroesophageal junction, witha residual lumen of less than 8 mm that appeared fibrotic. Thepatient also presented with impaction. Careful dilation of apredominantly fibrotic area is safe and offers an alternativemeans of management to restore enteral nutrition. In the abstractthat Leclercq et al. cite with respect to an increased riskof perforation,1 the patients underwent multiple dilations forchronic dysphagia with the use of balloons with an average sizeof 15 to 18 mm or an average Savary size of 36.8 French (12.26mm), indicating an aggressive target size for dilation. Endoscopicdilation should always be carefully performed, and the anatomyof every single stricture should always be studied before dilationis approached, regardless of the underlying pathology.
Rami Hawari, M.D. Digestive Disease Center Huntsville, AL 35801 rahawari{at}gmail.com
References
Shafi MA, Eisien GE, Al-Kawas FH, Benjamin SB. Increased risk of esophageal perforation with dilatation in patients with multiple esophageal webs (feline esophagus): a case control study. Gastrointest Endosc 1997;45:56-56. [ISI]
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