Esophageal Compliance Quantifies Epithelial Remodeling in Pediatric Patients with Eosinophilic Esophagitis

Background: The management of eosinophilic esophagitis (EoE) relies on the severity of esophageal eosinophilia, yet there is poor evidence of its prediction of esophageal fibrotic remodeling and subsequent complications such as dysphagia, food impactions, or strictures. Functional Luminal Impedance (FLIP) has had limited use in pediatric patients to evaluate esophageal tissue mechanics. We aimed to standardize the FLIP technique and to measure esophageal compliance in children with EoE in comparison to controls. Methods: Subjects were enrolled into a prospective observational study and had FLIP performed at the time of endoscopy. We calculated esophageal distensibility and compliance for the total and segmental esophagus independently (i.e., proximal, middle and distal esophageal segments). We evaluated esophageal biopsies for eosinophilia and epithelial remodeling, calculated endoscopy scores, and documented patient symptoms. Results: We enrolled 11 EoE and 12 controls subjects, aged 5–18 years old. While EoE subjects had lower esophageal compliance (p = 0.004) than controls, the difference in distensibility did not reach significance (p = 0.151). Epithelial remodeling severity was more strongly correlated with compliance than with distensibility. Epithelial remodeling scores ≥2 had a significant association with lower compliance both segmentally and in the entire esophagus (p = 0.029), but not with distensibility. Compliance measures were more sensitive in detecting subjects with remodeling score ≥2 than distensibility (79% versus 64%). Conclusion: Compliance is a more sensitive measure of esophageal epithelial remodeling in children compared to distensibility, and a more appropriate measure of esophageal tissue mechanics. Standardized placement of the FLIP catheter is important to accurately assess esophageal compliance. Address correspondence and reprint requests to Hayat Mousa, MD, AGAF, 3020 Children's Way MC5030, San Diego, CA 92123 (E-mail: hmousa@ucsd.edu); Maheen Hassan, MD, University of California San Diego, San Diego, CA United States (E-mail: m1hassan@ucsd.edu). Received 31 January, 2018 Accepted 15 October, 2018 Conflicts of interest and Sources of funding Financial support: This study was supported by the following NIH Grants: NIH/NIDDK DK07202 T32 Gastroenterology Training Grant (MH), NIH/NIAID AI092135 (SA), UL1TR001442 CTSA Funding (J.P) Potential competing interests: The authors declare no conflicts of interest. Specific author contributions: Experimental design: M.H, H.M, S.A, R.D; experimental execution: M.H, H.M, S.A, R.D, R.N; data processing: A.G; data analysis and interpretation: M.H, H.M, S.A, R.D, A.G.,J.P; manuscript writing/editing: M.H, H.M, S.A, R.D, A.G.,J.P. All authors have approved the final draft. Supplemental digital content is available for this article. Direct URL citations appear in the printed text, and links to the digital files are provided in the HTML text of this article on the journal's Web site (www.jpgn.org). © 2018 by European Society for Pediatric Gastroenterology, Hepatology, and Nutrition and North American Society for Pediatric Gastroenterology,

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