Transnasal Endoscopy: Easing Eosinophilic Esophagitis (EoE) Treatment Monitoring

Finding the most effective treatment for EoE can be a challenging process. Transnasal endoscopy decreases the burden of repeated endoscopies.

Eosinophilic gastrointestinal disorders are a chronic and complex group of diseases characterized by having abnormal numbers of eosinophils in parts of the GI tract. This results in chronic inflammation and tissue damage that can lead to a wide range of symptoms. Of these, eosinophilic esophagitis (EoE) is the most common, according to Rajitha D. Venkatesh, MD, MPH, a pediatric gastroenterologist at Nationwide Children’s Hospital and chair of the NASPHAN (North American Society for Pediatric Gastroenterology, Hepatology and Nutrition) Eosinophilic Gastrointestinal Disorders Special Interest Group (EGID SIG).

Rajitha Venkatesh, MD

“EoE is a recognized disease that is rare but has been increasing in prevalence globally. It is a diagnosis that requires an endoscopy or camera to assess for eosinophilic inflammation. Many patients with EoE may also have other atopic conditions such as asthma, eczema and IgE mediated food allergies. Our multidisciplinary team here at Nationwide Children’s takes care of many patients with EoE,” says Dr. Venkatesh.

Treatments for EoE include diet and medications, but the biggest challenge may be figuring out if the treatment is working.

“To determine if food is triggering a child’s EoE, we work with families to eliminate suspected or known food triggers, such as milk, wheat, eggs, soy, peanuts, tree nuts, and fish and shellfish,” says Dr. Venkatesh. “There is no specific testing currently to identify a child’s food trigger. And to further complicate the issue, some children may  have multiple foods that trigger their EoE.”

Medications such as proton pump inhibitors and topical corticosteroids have been successful in putting EoE into remission and helping patients symptomatically. However, in May 2022, the U.S. Food and Drug Administration (FDA) approved the first medication specifically to treat EoE: Dupilumab is a monoclonal antibody, or biologic, delivered via injection. It is approved for children age 1 and older who weigh at least 15 kilograms. Earlier this year, the first oral medication for EoE was approved: Eohilia (budesonide oral suspension) is a topical corticosteroid approved for patients aged 11 and older.

Any treatment option requires follow-up scopes to monitor efficacy. According to Dr. Venkatesh, a change in symptoms is not a reliable indicator of inflammation levels.

“While trying to sort out food triggers and/or assess medication response, follow-up can mean repeated scopes requiring sedation – upwards of three to six – over the first year of diagnosis to get to remission,” says Dr. Venkatesh. Considering that a traditional endoscopy procedure requires anesthesia, some patients and caregivers may be daunted at the prospect.

“At Nationwide Children’s, we offer transnasal endoscopy, specifically esophagoscopy, for children ages 8 and older with EoE,” says Dr. Venkatesh. “This office-based procedure allows us to monitor EoE inflammation without needing any anesthesia or an IV.”

During a transnasal endoscopy (TNE), the endoscope is inserted through the nose rather than the mouth while they are awake. Patients can use virtual reality goggles to help distract them during the procedure. According to Dr. Venkatesh, patients respond well and families are happy to have this option. They often have it done more than once when needing serial monitoring of their disease. Nationwide Children’s is one of a few pediatric centers offering TNE for EoE monitoring.

“Our multidisciplinary team at Nationwide Children’s works together to provide comprehensive care for this rare group of diseases. Patients and families have been so appreciative to have this alternative to sedated endoscopies and for our patient-centered approach,” says Dr. Venkatesh.

Reference:

Jenco, M. FDA approves first oral therapy for EoE. AAP News. 13 Feb 2024. https://publications.aap.org/aapnews/news/28180/FDA-approves-first-oral-therapy-for-EoE (Accessed 13 May 2024).

GI Kids. gikids.org/eosinophilic-esophagitis/ (Accessed 17 May 2024).

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