The FLIP “measures luminal cross sectional area (CSA) and pressure in the esophagus using impedance planimetry and serves as an adjunct to existing esophageal investigative tests. A distensible balloon encasing a catheter with multiple pairs of impedance electrodes is used, and the balloon is distended with fluid of known conductivity and volume.”
FLIP can be done at time of endoscopy.
Distensibility index (DI). This is the ratio of EGJ cross sectional area to intraballoon pressure is generally considered the most useful FLIP metric. Normal DI values in adults range from 3.1 to 9.0 m3/mm Hg. Lower values indicated reduced EGJ opening.
FLIP can complement the diagnosis of achalasia when manometry and barium studies are inconclusive or negative in patients with typical symptoms.
FLIP can be used to assess fibrostenotic remodeling of the esophagus in eosinophilic esophagitis.
Lumen diameter measured using FLIP in complex strictures can potentially guide management.
This review has several helpful figures to illustrate the type of visual data available. It also provides a standard protocol for using FLIP. The current limitations for FLIP include the lack of real-time software analysis of the data which hinders reporting, and limited data supporting use.
A Levine et al. Gastroenterol 2019; 157: 440-50. This study found that a Crohn’s Disease Exclusion Diet plus partial enteral nutrition induced sustained remission in a 12-week prospective randomized controlled trial with 74 children. At week 12, “76% of 37 children given CDED plus PEN were in corticosteroid-free remission compared with 14 (45.1%) of 31 children given” EEN followed by PEN. The associated editorial on pages 295-6 provides a useful diagram of various dietary therapy components for a large number of diets that have been given for IBD. The editorial recommends:
“For now, simple dietetic recommendations such as consuming a well-balanced diet prepared largely from fresh ingredients and thereby avoidance of emulsifiers and additives and processed foods are appropriate for all patients. In select patients,…a trial of dietary therapy alone with a diet such as CDED could be attempted for a short period of time, with close follow-up, and with agreement with the patient that failure to fully respond is an indication to escalate therapy.” More dietary trials are ongoing.
NJ Samadder et al Clin Gastroenterol Hepatol 2019; 17:1807-13. In this cohort from Utah 1996-2011 with 9505 individuals with IBD, 101 developed colorectal cancer. Standardized incidence ratio (SIR) for CRC in patients with Crohn’s disease was 3.4, in ulcerative colitis 5.2, in patients with primary sclerosing cholangitis 14.8. A family history of CRC increased the risk of CRC in patients with IBD to 7.9 compared to general population. Family hx/o CRC increased the SIR by about double the CRC risk in IBD patients without a family hx/o CRC.
CR Ballengee et al. Clin Gastroenterol Hepatol 2019; 17: 1799-1806. In this study with 161 subjects from the RISK cohort, the authors found that elevated CLO3A1 levels in subjects with CD was associated with the development of stricturing disease but was not elevated in those with strictures at presentation and in those who did not develop strictures.
AL Lightner et al IBD 2019; 25: 1152-68. Short- and Long-term Outcomes After Ileal Pouch Anal Anastomosis in Pediatric Patients: A Systematic Review. This review included 42 papers.
Rates of superficial surgical site infection, pelvic sepsis, and small bowel obstruction at <30 days were 10%, 11%, and 14% respectively.
Rates of pouchitis, stricture, chronic fistula, incontinence and pouch failure were 30%, 17%, 12%, 20% and 8% respectively with followup between 37-109 months.
Mean 24-hour stool frequency was 5.
MC Choy et al IBD 2019; 25: 1169-86. Systematic review and meta-analysis: Optimal salvage therapy in acute severe ulcerative colitis. Among 41 cohorts (n=2158 cases) with infliximab salvage, overall colectomy-free survival was 69.8% at 12 months. The authors could not identify an advantage of dose-intensification in outcomes, though this was used more often in patients with increased disease severity, “which may have confounded the results.”
Over the next 2 weeks or so, I am posting my notes/pictures from this year’s annual meeting. The first few days will review the postgraduate course. For the most part, I find the postgraduate course reassuring that I have kept up with current approaches; there is usually not a lot of new information but a solid review of the topics.
A recent retrospective study ( SS Baker et al. JPGN 2015; 61: 538-40) reported on changes in esophagitis over a 30 year period at one center. While the authors focus on the fluctuating percentage of esophagitis noted during three periods, in my opinion, they miss the opportunity to discuss more relevant findings.
Specifically, the authors note the following:
From 1980-88 (n=186 over 8 years) that 26.9% had esophagitis and 4.8% had >15 eos/hpf. Normal pathology in the esophagus was noted in 73.1%.
From 2000-2002 (n=321 over 2 years), 41.2% had esophagitis and 8.5% had >15 eos/hpf. Normal pathology in the esophagus was noted in 58.8%.
In the most recent period, 2011, (n=675 over 1 year), 31%* had esophagitis and 12.7% had >15 eos/hpf. Normal pathology in the esophagus was noted in 69%. *erroneously reported as 33%
What is baffling to me are the following:
Why the authors assert that there has been a fluctuating prevalence. In absolute terms, the increase in cases is marked, though one can argue that in earlier periods there may have been many undiagnosed cases.
Why the authors do not comment on the tremendous increase in the use of endoscopy in their discussion. In the first period, they were averaging ~23/year, the second period ~95/year and in the most recent period, they performed 675 in one year.
My take: This study shows that esophageal eosinophilia has been present for a long time and that identification of cases has increased considerably over 32 years. In addition, the use of endoscopy has increased markedly, yet the yield of abnormal findings remains similar.
Briefly noted: C Menard-Katcher et al. JPGN 2015; 61: 541-46. This retrospective study of 22 children showed that 55% had esophageal strictures identified by esophagram but not endoscopy.
Two important articles are provide additional insight into eosinophilic esophagitis (EoE).
In the first (Gastroenterol 2013; 145: 1230-36), the authors performed a retrospective review of the Swiss EoE Database (SEED). This SEED should not be confused with our SEED center (Home- The SEED Center of Atlanta– SouthEast Eosinophilic …). While the database contains 783 EoE patients, only 200 who were followed by the senior author and had complete data were included. The enrollment period dates back to 1989.
Demographics: 153 men, mean age 39 years old, 94.5% had dysphagia at time of diagnosis and 35.5% had chest pain. 66% had concomitant allergies.
Terminology: The authors defined strictures as low-grade if a standard 9 mm endoscope could pass but met resistance, intermediate if a 6 mm endoscope could pass, and high-grade if it could not be passed with a 6 mm endoscope.
37.5% (n=75) had strictures (other endoscopic findings noted in Table 2)
Peak eosinophil count (median): 35 proximally and 28 distally
Figure 2 showed the evolution of endoscopic features based on diagnostic delay. With increasing diagnostic delay, there developed a preponderance of a mixed fibrotic/inflammatory picture whereas in those whose symptoms were of much shorter duration, the endoscopic features were often inflammatory without fibrosis.
For example, if diagnostic delay was between 0-2 years, then fibrotic findings were noted in 46.5%; in contrast, 87.5% had fibrotic features if symptoms had been present for > 20 years.
Strictures increased from 17.2% in those without significant diagnostic delay to 70.8% in those with symptoms present for > 20 years.
The authors note that diagnostic delay was greatest in those who developed symptoms in the first decade of life.
Study limitations: The categorization of strictures is straightforward; however, newer tools like the EndoFlip can detect esophageal narrowing more accurately. Other limitations are related to retrospective nature of study and its reliance on patient’s reported outcomes (subject to recall bias). Thus, the estimation of diagnostic delay may be inaccurate.
Take home message:
This article reinforces the concept that the presentation of EoE changes with time and that the long-term consequence of untreated EoE is increasing fibrosis and stricturing of the esophagus.