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to evaluate the patient with idiopathic recurrent pancreatitis, how to diagnose and
manage pancreas divisum, sphincter of Oddi dysfunction, and autoimmune
pancreatitis.
Case studies diagnosing and evaluating etiologies for chronic pancreatitis in
alcohol abusers and those without a history of alcohol use are reviewed. The utility
of the secretin-stimulated MRCP is discussed as are the management of chronic
pain in chronic pancreatitis and the management of pancreatic stones.
In a section on GI oncology, the author provides case studies demonstrating the
use of chemotherapy in colon cancer, Lynch syndrome, EGJ adenocarcinoma, and
pancreatic cancer. Different management for right-sided vs. left-sided colon cancer
is discussed. The different approaches to chemotherapy, immunotherapy, and surgi-
cal therapy in Lynch syndrome are reviewed. There is a wide-ranging discussion of
different responses to chemotherapy and immunotherapy in different GI cancers.
There are case studies reviewing the management of refractory benign esopha-
geal strictures, the use of stents in benign and malignant esophageal strictures, and
the role of stents in extrinsic malignant esophageal obstruction. Issues concerning
the diagnosis and staging of pancreatic cancer and the diagnosis of pancreatic can-
cer when preliminary tests are negative are discussed.
A PharmD specializing in GI pharmacology provides case studies analyzing the
use of GI drugs in treating EOE, HP, HBV, HCV, IBS, IBD, pancreatic insuf-
ciency, and autoimmune hepatitis. Issues concerning the use of budesonide and
uticasone are discussed. Obstacles with patients using quadruple therapy for HP
are outlined. Many more challenges are reviewed. Important drug-drug interactions,
drug-food interactions, drug toxicity, and insurance coverage are highlighted.
W. H. Sobin
https://t.me/medicina_free
7© The Author(s), under exclusive license to Springer Nature
Switzerland AG 2023
W. H. Sobin et al. (eds.), Managing Complex Cases in Gastroenterology,
https://doi.org/10.1007/978-3-031-48949-5_2
Chapter 2
Eosinophilic Esophagitis
PatrickSanvanson
Case 1 A 28-year-old man presents with a food impaction after eating a turkey
sandwich. He has a history of food sticking over the last couple of years but has
always gotten it down by swallowing water. He tends to cut his food into small
pieces, but this time he swallowed a too large piece of meat. On endoscopy, he
appears to have a mildly narrowed esophagus; it has multiple rings and some lon-
gitudinal furrows. The piece of chicken is removed with a Roth net. Biopsies show
80eos/hpf in the upper and lower esophagus.
He is placed on pantoprazole but feels like food continues to stick
intermittently.
Would you agree with that initial treatment and how would you pro-
ceed now?
Yes, it sounds like he has a classic presentation of eosinophilic esophagitis with
greater than 15 eosinophils per high-power eld. Obviously, you have the other
components with the rings and the furrows, but those won’t necessarily make the
diagnosis of eosinophilic esophagitis (EOE).
The histologic diagnosis seems pretty clear for EOE, and the history of food
impaction is one of the more common presentations of eosinophilic esophagitis.
They placed him on a PPI right away, which I agree with. There is usually a delay
in diagnosis of EOE, and in this case, it sounds like he’s had symptoms going on for
the last couple of years.
After starting pantoprazole, his symptoms are not completely relieved. The ques-
tion I ask in patients with incomplete relief is as follows: Is he compliant with the
pantoprazole, and is he taking it correctly?
P. Sanvanson (*)
Division of Gastroenterology and Hepatology, Department of Medicine, Medical College of
Wisconsin, Milwaukee, WI, USA
e-mail: psanvans@mcw.edu
https://t.me/medicina_free
8
I always like to bring these patients back into the clinic, to explain the disease
EOE, and to inform them that they have one of the more common complications,
which is a food impaction. I let him know that this is a medical condition that we
can manage but can’t necessarily cure and then to also give him insight into the
therapy itself.
So, he’s been placed on proton pump inhibitor therapy, and the question is as
follows: Why do EOE patients respond to this? Is it because you’re managing acid
reux and that’s stimulating the disease, or is it because you’re blocking eotaxin-3
expression, which subsequently has an effect on eosinophil recruitment?
Obviously, PPIs have been used extensively to treat EOE, but this patient is hav-
ing inadequate relief. So, we question what dose he’s on, how long he’s been on the
medication, whether he is compliant with the medication dosing, and how is he tak-
ing the pantoprazole, before we conclude that he hasn’t necessarily responded to
PPI therapy.
Do you normally start with pantoprazole or a different PPI and what dose
do you like to start with?
It varies and is generally dependent on insurance coverage. Numerous PPIs have
been tried with EOE.If I’m using pantoprazole, I will usually start with 40mg twice
a day. I usually err on the side of using high-dose PPI.This may be supra- therapeutic,
but I just don’t want to underdose these patients. If I’m using omeprazole, I would
also use 40mg twice a day. So, the key is that whatever PPI you choose, always
make sure to err on the side of the higher dose, just so you don’t underdose them
prior to their repeat endoscopy.
There have been studies looking at the potency of different PPIs, but these were
based on GERD data, not EOE data, so, we can’t be sure this extrapolates to
EOE.However, in GERD, pantoprazole is considered one of the least potent acid-
suppressing PPIs, while rabeprazole and dexlansoprazole are the most potent.
Omeprazole and esomeprazole are in the middle.
.
The patient is taking pantoprazole 40mg bid and has been taking it on an empty
stomach a half hour before meals for the past 8 weeks. While there might be mild
improvement, he is still complaining of dysphagia.
What would you do, would you repeat endoscopy, would you dilate the
esophagus, and would you start him on steroids?
In terms of symptoms, it’s always hard with EOE patients, because I feel like
their symptoms vary so much from person to person, and a lot of these patients no
longer know what normal is.
In making therapeutic decisions, symptoms can be confusing, and so I usually
like to guide my decision-making on endoscopic evaluation with biopsies. So, I like
to treat the patient for 8–10 weeks, and then, at that point I would go in and do
another EGD and get repeat biopsies of the esophagus.
I don’t typically dilate on that follow-up endoscopy. However, if there is an iso-
lated ring in the distal esophagus at the GE junction level, I will often dilate those
patients on the subsequent EGD. Also, if I am dealing with a narrow caliber
P. Sanvanson
https://t.me/medicina_free
9
esophagus where the only scope I can advance is an ultrathin endoscope, I feel those
patients are at very high risk of food impaction, so, I will frequently do a bougie
dilation on the follow-up EGD.
However, if there is no severe narrowing, only a mild diffuse narrowing, where
the esophageal diameter is well above 12mm, and they’re able to chew their food
and get it down, I will not dilate at the 8-week follow-up. In those patients, I will
give them more chances to respond to additional medical therapy. The reason I try
to defer dilation as long as possible is that we’ve seen many patients that have been
on medical therapy, and once you get their inammation under control, the esopha-
gus starts to remodel and a lot of their stricturing disease just goes away. I’m not
necessarily hesitant to dilate their esophagus, but if it’s not absolutely necessary,
I’d rather avoid it. With any type of procedure, there are potential complications,
and in terms of dilating patients with EOE, the initial reports were concerning due
to an increased perforation risk. However, those initial concerns have been
mitigated.
However, it is clear that a lot of EOE patients may experience signicant chest
discomfort and chest pain post-dilatation. So, if I’m going to dilate them, I warn
them ahead of time that if we do dilate you, you might experience some degree of
chest discomfort post-procedure.
However, not everyone is comfortable dilating EOE.You mustn’t be too aggres-
sive with dilation, start with lower caliber dilators, and then slowly move your
way up. Using these precautions, the risk is fairly low. You have to realize, in treat-
ing EOE that this is not a condition that is going to lead to cancer or shorten
someone’s life, so it is well worthwhile to be conservative, to go out of your way
to avoid a perforation. This is one of the reasons why I’m not too aggressive with
dilation.
How will the results of endoscopy and biopsy on that second EGD affect
your management plans?
Obviously, the main thing is measuring the response to therapy. So, you are look-
ing for histologic improvement, and you are evaluating endoscopic improvement
with regard to stricturing and narrowing. These are important, along with symptom
improvement as well.
With our biopsies, the goal, from a histologic standpoint, is to have essentially
zero eosinophils per high-power eld, but typically, we accept less than 15 eosino-
phils per high-power eld as an adequate goal for response. However, there are
some patients where I’ll start up PPI therapy after the initial endoscopy showed an
eosinophil count of 100/hpf, and they may go down to 14 eos/hpf with treatment,
and I say, okay, that’s an adequate response.
However, then you have subsets of patients that present with a low-grade eosino-
philia like 25eos/hpf, and now they’ve down to 13 or 14. So you’ll wonder, if that
is really a signicant response, or not, but usually we are also taking into account
any improvement in symptoms or endoscopic appearance.
If their response to therapy is suboptimal and the patient doesn’t have a decrease
in their eosinophil count to less than 15eos/hpf, what do we do next? Then, you
2 Eosinophilic Esophagitis
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started talking about alternate therapies. Our other therapies involve making a deci-
sion between using topical steroids versus doing an elimination diet. As of May
2022, there is another therapy, the newly approved dupilumab.
So, I always give my patients the option of choosing between elimination diet
versus topical steroids. Unfortunately, none of the topical steroids are FDA-approved
therapies. The two most commonly used are budesonide and uticasone which have
been found to be relatively equivalent in terms of clinical response.
Unfortunately, a lot of our guidance on steroid choice depends on cost. I don’t
necessarily have a favorite, budesonide, or uticasone. I base it more on the cost to
the patient and the convenience of taking the particular regimen. From the stand-
point of topical steroids, the goal is to decrease the inammation within the
esophagus.
If I’m using budesonide, I start at 1mg twice a day. If we can get their insurance
to cover a compounded version of budesonide, it is much simpler for the patient to
use this, but, unfortunately, a lot of insurance companies don’t cover the com-
pounded version, which makes the use of budesonide much more difcult. Those
patients have to compound their own budesonide. They take respules of budesonide,
which are designed for use with nebulizers in asthma, mix the liquid medicine in
these respules with a high viscosity agent, usually sucralose or honey, and then
swallow the admixture. You can see how that’s pretty cumbersome for a lot of
patients to take and requires a patient who is very motivated and compliant.
The other option is uticasone, which is administered by inhaler, but you have to
educate the patient to spray it in their mouth and not inhale it into their lungs. There
have been studies that show a number of patients make that mistake. So, it’s key to
educate patients on how to take uticasone properly. From a dosing standpoint, I
recommend two puffs at 220μg per puff, i.e., 440μg twice a day. Occasionally, I
will go up to 880μg twice a day in patients who are initial non-responders. Some
patients who are initial non-responders will respond to 880μg bid. Once I start ste-
roids, I’ll usually wait 8–10 weeks then re-biopsy the esophagus and assess the
response.
The response rate to elimination diets is thought to be above 50%. Obviously,
this requires a very dedicated patient that they have to be extremely compliant with
the diet. It requires working closely with our GI dietician as well. When we start an
elimination diet, we also repeat endoscopy after each manipulation to gauge
response to the withdrawal of a particular food group. When we decide to reintro-
duce a particular food, we also repeat endoscopy to gauge response. l will explain
the elimination diet strategy to see if this is something the patient wants to pursue.
In addition to being on a strict diet, the other challenging factors are the cost and the
time required for multiple endoscopies to assess response.
In addition, our Wisconsin patients are not thrilled about the idea of restricting
wheat and dairy, the two major food groups that are frequently eliminated. I do have
a number of patients that are on elimination diets, but unfortunately these are the
select few who are very compliant people that are willing to put in the time and the
work to do the elimination diet. However, if somebody has some hesitancy, they feel
like they can’t do it, we try our other options.
P. Sanvanson
https://t.me/medicina_free
11
Pantoprazole is continued at 40mg BID.The patient opts to be placed on ste-
roids, and uticasone is started at 440mg bid. Repeat endoscopy with biopsy is
done 8 weeks later and shows histologic response. Symptomatically, the patient is
doing very well with much-improved swallowing.
How long will you maintain PPIs and steroids?
We have learned that these patients will need some type of long-term mainte-
nance of whatever therapy they’re on, as EOE is a chronic illness. We know that
when they stop the therapies most people will have a recurrence of the esophageal
eosinophilia and, then, subsequently, the scarring and other classic ndings of EOE.
From a PPI standpoint, if they’re doing well on twice a day dosage, I’ll decrease
it to once a day and see how they do from a symptom standpoint. If they’re doing
ne, I won’t repeat the endoscopy, but if they’re not doing well, I may consider
repeating the biopsies.
Topical steroids are a little trickier. I usually keep them on some type of long-
term therapy. However, we know that if you decrease the maintenance dose of
budesonide or uticasone from their initial induction dose, then probably about
25–50% of people will have a recurrence of their esophageal eosinophilia. So, we
have some shared decision-making to decide whether to lower the dose. If patients
are happy, and they’re doing well on their current regimen, I give them the option of
maintaining their current dose of topical steroids without taper.
We do see some problems with steroid compliance since it’s a twice-daily regi-
men. If it’s very cumbersome for the patient, I may decrease it from twice a day to
once a day and see how they do, but we do know from randomized, placebo-
controlled studies that a lot of these patients, essentially 50% or more, may have a
recurrence of their esophageal eosinophilia within 6-month time.
It sounds like you are keeping most people on these medicines indenitely
Exactly, assuming that they’re getting some benet from them, I always compare
it to blood pressure issues. Typically, when people have hypertension, unless you
get rid of some other factor, it becomes a lifelong management issue. With EOE,
there may be some things that we can modify, like diet, that may help maintain
remission. Unfortunately, most of the studies suggest a recurrence of eosinophilia
and recurrence of symptoms once you stop their maintenance therapy.
In which cases will you use dupilumab therapy?
Dupilumab is basically the rst FDA-approved medication for EOE. It’s obvi-
ously a systemic therapy that should target some of these remodeling pathways and
inammatory pathways and hopefully prevent brostenotic disease. There are a
number of other agents in the pipeline that are coming out as well.
Dupilumab is thought to work by inhibiting signaling of interleukin 4 and 13. It’s
a monoclonal antibody against IL-4 receptor. Historically, it’s been approved for
other disease processes, including atopic dermatitis, asthma, chronic rhinosinusitis,
and now EOE.The data are quite strong in terms of response of esophageal eosino-
philia, the classic endoscopic ndings of EOE, and symptom improvement as well.
The population, for sure, that may benet from this treatment are those who are
refractory to PPIs and steroids. Patients who nd budesonide or uticasone too
cumbersome to take may also be good candidates. Right now, we have to see where
2 Eosinophilic Esophagitis
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dupilumab lands in terms of insurance coverage. Dupilumab is given as one injec-
tion once a week. We do have a number of patients that are refractory to PPI therapy
and topical steroid therapy who will be considered for dupilumab therapy in the
near future.
What would be very interesting is to use dupilumab in our EOE patients who also
have eosinophilic asthma or atopic dermatitis. I think these patients should be per-
fect candidates, where you try to reduce the medications they’re on, save them
money, and hopefully give them back some more quality of life. In the long term, if
you can treat multiple illnesses with the same medication, it would be a signicant
advantage.
So, I think that if patients fail to respond to combination therapy, then you should
at least introduce the idea of using dupilumab therapy.
Besides for dysphagia, what other symptoms do you tend to see in your EOE
patients?
I think there are variable presentations, but the other common complaint besides
dysphagia is heartburn. The hard part in that scenario is deciding whether the heart-
burn is due to the EOE or is it reux-related. Sometimes, that requires additional
investigations to gure that out.
Another symptom we occasionally see is nausea, which is probably more com-
mon in the pediatric population. Our pediatric colleagues are more likely to see
EOE presenting with food intolerance and weight loss in their patients.
We occasionally see bloating, although not that commonly. Regurgitation is
more often seen with reux disease than with eosinophilic esophagitis. However, if
someone has an EOE-related stricture, then they’re more likely to have esophageal
reux and other related issues depending on the severity of the stricture.
However, once again, these EOE patients have varied symptoms that don’t nec-
essarily correlate with the severity of their endoscopic ndings. Some patients have
a wide-open esophagus yet have severe symptoms, while other patients may have
close to a pinhole esophagus and will have essentially no symptoms. So, evaluating
symptoms is important but can be misleading.
Case 2 Another patient, a 32 year-old man, presents with a food impaction. He
has a known history of EOE but got lost to follow-up 10 years ago, shortly after
diagnosis. He has had progressive dysphagia which he has managed by cutting his
food into small pieces, avoiding tough meats, like steak, no salads. In spite of this,
food is frequently getting stuck, and now, he presents to the ER because a piece of
sausage got stuck and he was unable to vomit it out. On endoscopy, the esophagus
is quite narrow. The food stuck in the mid-esophagus is able to be removed. The
endoscope is unable to be passed all the way down the esophagus because it is
too narrow.
How do you manage a patient who has a long duration of untreated EOE
and has developed signicant narrowing, signicant brosis?
I’ve seen a number of patients that have had more brostenotic disease. It’s
presumed that there is more brosis because the disease has been persisting
P. Sanvanson
https://t.me/medicina_free
13
untreated for a longer period of time. EOE starts as an inammatory process, and
then over time, the inammation progresses and develops into more and more
brotic disease.
I think the pathophysiology is probably fairly similar to patients with more acute
presentations. EOE starts as an immune response to some type of antigen stimulus,
whether it’s a food or whether it’s environmental, with probably some degree of a
genetic abnormality involved as well.
We do know that in a long term, some patients will develop a narrow caliber
esophagus, as a result of tissue remodeling and brosis. Subsequently, there is a
change in the mechanical properties of the esophagus, where brosis leads to issues
with decreased distensibility and dysmotility.
The medical treatment of these patients is similar to those with a normal caliber
esophagus. However, because of the severe narrowing of the esophagus, I may mod-
ify the particular medicine regimens that they’re on. I might give lansoprazole,
which is available as an oral dissolvable formulation. I may also prescribe a capsule
version of omeprazole, rather than the pill form, where you open up the capsule and
put the medicine in applesauce and swallow that just to make certain that they’re
actually able to get their pills down and get an adequate trial of the medication.
In addition, if there is severe narrowing, with an extremely narrow caliber esoph-
agus, I’ll frequently have to go down with an ultrathin endoscope and begin gradual
dilation over a guidewire. When I dilate, I am not too aggressive, starting off. I’ve
had patients that come in with a 5-mm esophagus. I may do a 21 French bougie
dilation, which is about 7mm. Initially, we might tell them to stay on a liquid diet,
or more of a pureed type of diet, as opposed to swallowing solid foods. One of the
more important parts of education is to make sure that the patient takes his time with
eating, chewing his food extremely well, and drinking a lot of liquid in-between
bites as well.
If it is the very narrow esophagus, how often would you repeat dilation?
A stricture from EOE acts differently than a GERD-related stricture. In a tight
GERD-related stricture, we might bring them back weekly, but in an EOE-related
stricture I want to give their medications time to work. I feel that, with a lot of these
EOE patients, once you treat the inammatory component of the disease with your
medication, the dilations are more effective, compared to long-standing peptic,
GERD-related strictures.
So, if they’re able to tolerate something liquid and perhaps other foods as well,
usually I’ll try to go 8 weeks between dilations. If, however, the patients contacting
me say they’re not doing well, they’re miserable, and everything is getting stuck,
then I’ll bring them back earlier, at 4-week intervals. However, I’ve never really had
to dilate them more frequently than that.
A part of the reason is that I just want to see what their response to therapy is. A
lot of times, patients are able to tolerate some type of diet once they’re on medical
therapy, they’re maintaining their weight, and they’re able to maintain their hydra-
tion. However, it’s also important with EOE patients that every time you see them
you try to conrm compliance with medication. I had a patient that came in with an
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extremely narrow caliber esophagus. I did six or seven dilations on him, and he just
wasn’t improving. He wasn’t responding to PPI therapy, and he wasn’t responding
to topical steroid therapy. We even tried switching his steroid formulations, and
there was still no improvement. Then, after multiple ED visits, he nally confessed
that he was not complying with taking his meds the way he was instructed. Once he
started complying with the medication instructions, there was rapid remodeling of
the esophagus and I was quickly able to dilate him sufciently.
P. Sanvanson
https://t.me/medicina_free
15© The Author(s), under exclusive license to Springer Nature
Switzerland AG 2023
W. H. Sobin et al. (eds.), Managing Complex Cases in Gastroenterology,
https://doi.org/10.1007/978-3-031-48949-5_3
Chapter 3
Oropharyngeal Dysphagia
PatrickSanvanson
A 78-year-old man with a history of Parkinson’s disease is complaining of dyspha-
gia. A swallowing evaluation suggests that he has oropharyngeal dysphagia.
Despite maneuvers by the speech therapist, he continues to have problems.
How do you manage patients with oropharyngeal dysphagia?
You always need to know the underlying pathophysiology of the dysphagia.
Is it stroke-related? Is it related to a neuromuscular issue, like ALS, or Parkinson’s
disease? We also see some patients that have head and neck cancer, and they’ve had
surgical therapy or radiation therapy that has resulted in dysphagia. So, you always
want to consider whether the underlying condition can be rehabilitated and whether
improvement is possible? If you’re dealing with ALS, you’re very limited from a
therapy standpoint because the disease progresses, which is often the case in
Parkinson’s disease as well. On the other hand, you have some stroke patients that
may have a signicant degree of rehabilitative potential. When there are no obvious
explanations for the dysphagia, we may be witnessing idiopathic oropharyngeal
dysphagia, and these patients may present in a variety of ways with various rehab
potential.
However, whenever I have a patient who says they have difculty swallowing, I
always ask them, “Do you feel like you have coughing when you swallow? Do you
ever feel like things go down the wrong pipe? Have you ever felt that you needed to
have the Heimlich maneuver, because you were unable to breathe when these epi-
sodes were occurring?”
There are other patients who may be completely asymptomatic but present with
aspiration pneumonia. Obviously, the most important thing that we want to avoid
P. Sanvanson (*)
Division of Gastroenterology and Hepatology, Department of Medicine,
Medical College of Wisconsin, Milwaukee, WI, USA
e-mail: psanvans@mcw.edu
https://t.me/medicina_free
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