Background & Aims Little is known about the diagnostic utility of the eosinophilic esophagitis (EoE) endoscopic reference score (EREFS), and how scores change in response to treatment. We investigated the operating characteristics of the EREFS in diagnosis of EoE, how the score changes with treatment, and ways to optimize scoring system. Methods We performed a prospective study of adults undergoing outpatient upper endoscopy from August 2011 through December 2013 at the North Carolina School of Medicine. Incident cases of EoE were diagnosed per consensus guidelines and were treated with topical steroids or dietary elimination (n=67); 144 subjects without EoE were included as controls. EREFS scores were compared between cases and controls. For EoE cases, scores were compared before and after treatment. Area under the receiver operator characteristic curve (AUC) analysis was used to determine diagnostic utility of the EREFS system. An iterative analysis was performed to determine optimal EREFS scoring weights. Results The mean total EREFS score was 3.88 for EoE cases and 0.42 for controls (P>.001); the score identified subjects with EoE with an AUC of 0.934. After treatment of EoE cases, the mean score decreased from 3.88 to 2.01 (P>.001). This change was more prominent for patients with a histologic response (reduction to <15 eos/hpf), compared with non-responders; post-treatment scores were 0.45 for responders vs 3.24 for non-responders (P<.001). A weighted scoring system that doubled exudates, rings, and edema scores maximized the responsiveness of the total EREFS score. Conclusions The EREFS classification system identifies patients with EoE an AUC of 0.934; the score decreases with treatment, and histologic responders have significantly lower scores than non-responders. This system can therefore be used to identify individuals with EoE and used as an endoscopic outcome measure to follow their response to treatment.

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Background & Aims The goal of treatment for Barrett’s esophagus (BE) with dysplasia is complete eradication of intestinal metaplasia (CEIM). The long-term durability of CEIM has not been well characterized, so the frequency and duration of surveillance are unclear. We report results from a 5-year follow-up analysis of patients with BE and dysplasia treated by radiofrequency ablation (RFA) in the randomized controlled Ablation of Intestinal Metaplasia Containing Dysplasia (AIM) trial. Methods Participants for the AIM dysplasia trial (18–80 years old) were recruited from 19 sites in the United States and had endoscopic evidence of non-nodular dysplastic BE ≤8 cm in length. Subjects (n=127) were randomly assigned (2:1 ratio) to receive either RFA (entire BE segment ablated circumferentially) or a sham endoscopic procedure; patients in the sham group were offered RFA treatment 1 year later, and all patients were followed for 5 years. We collected data on BE recurrence (defined as intestinal metaplasia in the tubular esophagus) and dysplastic BE recurrence among patients who achieved CEIM. We constructed Kaplan-Meier estimates and applied parametric survival analysis to examine proportions of patients without any recurrence and without dysplastic recurrence. Results Of 127 patients in the AIM Dysplasia trial, 119 received RFA and met inclusion criteria. Of those 119, 110 (92%) achieved CEIM. Over 401 person-years of follow-up (mean 3.6 years per patient, range 0.2 – 5.8 years), 35 of 110 (32%) patients had recurrence of BE or dysplasia, and 19 (17%) had dysplasia recurrence. The incidence rate of BE recurrence was 10.8 per 100 person-years overall (95% CI, 7.8 – 15.0); 8.3 per 100 person-years among patients with baseline low-grade dysplasia (95% CI, 4.9 – 14.0), and 13.5 per 100 person-years among patients with baseline high-grade dysplasia (95% CI 8.8 – 20.7). The incidence rate of dysplasia recurrence was 5.2 per 100 person-years overall (95% CI 3.3 – 8.2); 3.3 per 100 person-years among patients with baseline low-grade dysplasia (95% CI 1.5 – 7.2), and 7.3 per 100 personyears among patients with baseline high-grade dysplasia (95% CI 4.2 – 12.5). Neither BE nor dysplasia recurred at a constant rate. There was a greater probability of recurrence in the first year following CEIM than in the following 4 years combined. Conclusions In this analysis of prospective cohort data from the AIM dysplasia trial, we found BE to recur after CEIM by RFA in almost one-third of patients with baseline dysplastic disease; most recurrences occurred during the first year after CEIM. However, patients who achieved CEIM and remained BE free at 1 year after RFA had a low risk of BE recurrence. Studies are needed to determine when surveillance can be decreased or discontinued; our study did not identify any BE or dysplasia recurrence after 4 years of surveillance.

Objectives Esophageal dilation is commonly performed in eosinophilic esophagitis (EoE), but there are few long-term data. The aims of this study were to assess the safety and long-term efficacy of esophageal dilation in a large cohort of EoE cases and determine the frequency and predictors of requiring multiple dilations. Methods We conducted a retrospective cohort study in the University of North Carolina EoE clinicopathological database from 2002-2014. Included subjects met consensus diagnostic criteria for EoE. Clinical, endoscopic, and histologic features were extracted, as were dilation characteristics (dilator type, change in esophageal caliber, total number of dilations) and complications. Patients with EoE who had undergone dilation were compared to those who did not and also stratified by whether they required single or multiple dilations. Results Of 509 EoE patients, 164 were dilated a total of 486 times. Those who underwent dilation had a longer duration of symptoms prior to diagnosis (11.1 vs. 5.4 yrs, p<0.001). 95 patients (58%) required >1 dilation (417 dilations total, mean of 4.4 ± 4.3 per patient). The only predictor of requiring multiple dilations was a smaller baseline esophageal diameter. Dilation was tolerated well, with no major bleeds, perforations, or deaths. The overall complication rate was 5%, primarily due to post-procedural pain. Of 164 individuals dilated, a majority (58%, or 95/164) required a second dilation. Of these individuals, 75% required dilation within 1 year. Conclusions Dilation in EoE is well-tolerated, with a very low risk of serious complications. Patients with long-standing symptoms prior to diagnosis are likely to require dilation. More than half of those dilated will require multiple dilations, often needing a second procedure within one year. These findings can be used to counsel patients with fibrostenotic complications of EoE.

Objectives Radiofrequency ablation (RFA) of Barrett’s esophagus (BE) is safe and effective in eradicating dysplasia and intestinal metaplasia and may reduce rates of esophageal adenocarcinoma (EAC). We assessed rates of and risk factors for disease recurrence after successful treatment of BE with RFA. Methods We performed a retrospective cohort study of patients who completed RFA for dysplastic BE or intramucosal carcinoma (IMC), achieved complete eradication of dysplasia (CE-D) or intestinal metaplasia (CE-IM), and underwent subsequent endoscopic surveillance at a single center. Rates of disease recurrence and progression were determined. Patients with and without recurrent disease were compared to determine risk factors for recurrence. Results 262 subjects underwent RFA during the study period. Of these, 119 and 112 patients were retained in endoscopic surveillance after CE-D and CE-IM, respectively. Median observation time was 397 days (range: 54-1668 days). Eight patients (7% of those with CE-IM) had recurrent disease after a median of 235 days (range 55-1124 days). Progression to IMC (n=1) or EAC (n=2) occurred in 3 of these 8 patients, all of whom had pre-ablation high-grade dysplasia (HGD). Five patients had recurrence of non-dysplastic BE (n=3), low-grade dysplasia (n=1), and HGD (n=1). During 155 patient-years of observation, recurrence occurred in 5.2%/year, and progression occurred in 1.9%/year. No clinical characteristics were associated with disease recurrence. Conclusions In patients with BE and dysplasia or early cancer who achieved CE-IM, BE recurred in ~5%/year. Patient characteristics did not predict recurrence. Subjects undergoing RFA for dysplastic BE should be retained in endoscopic surveillance.