Esophageal Food Impaction in Adults May Portend EoE Diagnosis

A recent study conducted in Switzerland sought to understand the natural history of patients lost to follow-up after obtaining treatment for esophageal food impaction (EFI), a gastrointestinal emergency that is on the rise.

Writing in Clinical Gastroenterology and Hepatology, the authors said the increase in EFI can be attributed to an increasing incidence and prevalence of eosinophilic esophagitis (EoE).

EFI, which has an increasing incidence of around 17 per 100,000 people, may be the first signal of EoE. Understanding why EFI first occurred is key to avoiding future episodes, since esophageal perforation or pulmonary complications are a risk, and it is “highly important not to miss a new diagnosis of EoE,” the authors said.

More than half of patients are lost to follow up after EFI, yet without continued attention, esophageal symptoms and recurrent EFI may continue. Untreated or inadequately treated EoE could lead to fibrosis and strictures, and the risk of EFI can be reduced with regular intake of swallowed topical corticosteroids in patients with EoE.

The researchers identified 125 patients treated at their center for EFI between January 2015 and September 2021. According to the center’s policy, every patient treated for an EFI should receive a written follow-up appointment; if that appointment is missed, the patient is called, and whether or not the person is reached, a second written appointment is mailed to the home address. If that appointment is missed as well, the patient is classified as lost to follow-up.

Of the 125 patients with EFI, 25 (20%) were lost to follow-up, 22 were male (88%), and the median age at the time of the EFI was 47 (range, 23-69) years.

Researchers conducted a retrospective chart review to uncover real world data (RWD) on these patients, and then attempted to contact them at least 3 times. Nineteen of the 25 patients (76%) were successfully reached by phone. About 58 months passed between the EFI and the follow-up phone call.

When asked why they did not return for their follow-up appointment, the most common reason cited by patients was that they had no symptoms, followed by:

• The appointment was time consuming
• They did not think it was necessary
• Reason unknown
• Cost
• They saw another gastroenterologist

However, for some patients, symptoms continued:

• 10 (53%) reported continued dysphagia
• 11 (58%) had to change their eating behavior (ie, eat more slowly)
• 3 (16%) had 1 further EFI each (6, 30, and 38 months after the first EFI)
• 7 (37%) patients ultimately had a follow-up gastroscopy with the researchers, who diagnosed EoE
• 5 of the 7 began EoE therapy

After reviewing all of the data, 7 of the 25 patients (28%) received a diagnosis of EoE according to established criteria. One other patient had a diagnosis of lymphocytic esophagitis (4%). In 5 other patients (20%), EoE was clinically and endoscopically suspected, but did not fulfill all diagnostic criteria due to missing biopsies.

Ten patients (40%) received a diagnosis of gastroesophageal reflux disease, and for 2 individuals (8%), no diagnosis could be made.

The authors said this is the first study to outline the natural course of patients lost to follow-up after experiencing an EFI, and they said their results might be underestimated.

They pointed out that “a follow-up endoscopy will result in a diagnosis of EoE in the majority of patients resulting in therapeutic consequences.”

Given that the typical delay in obtaining a diagnosis of EOE is about 6 years, an episode of EFI is an opportunity to diagnose a chronic but treatable condition, the authors said, assuming that esophageal biopsies can be obtained during emergency treatment.

Reference

Murray FR, Kreienbühl A, Straumann A, Biedermann L, Schreiner P. Natural history of patients lost to follow-up after esophageal food impaction. Clin Gastroenterol Hepatol. Published online July 19, 2022. doi:10.1016/j.cgh.2022.07.007.