P3338 - Refractory Adult Fibrostenotic Phenotype Eosinophilic Esophagitis Treated With Dupilumab

Kevin Groudan, MD, John Miller, MD
University of Massachusetts Chan Medical School-Baystate, Springfield, MA

Introduction: Eosinophilic esophagitis (EoE) is a chronic allergen-mediated inflammatory disease of the esophagus. Untreated EoE can progress from an inflammatory to fibrostenotic phenotype, characterized by esophageal fibrosis, remodeling and strictures. Dupilumab was recently approved for the treatment of EoE in adult and adolescent patients. A key exclusion criteria from Dellon et al.’s landmark study was any esophageal stricture requiring dilation or unable to be passed with a standard upper endoscope. We present an adult patient with refractory fibrostenotic phenotype EoE who had clinical and endoscopic improvement with Dupilumab therapy.

Case Description/Methods: A 31-year-old man with a reported history of recurrent esophageal strictures diagnosed at an outside hospital presented to gastroenterology clinic with chronic dysphagia and an abnormal barium study showing severe upper esophageal stenosis. He was only able to tolerate pureed foods and liquids. Upper endoscopy revealed stacked esophageal rings suspicious for eosinophilic esophagitis and severe, luminal narrowing that could not be passed with a 6.6 mm gastroscope. The esophageal stricture lumen was measured to be approximately 4 mm using fluoroscopy. The esophagus was dilated with a 5 mm savory after passing wire under fluoroscopic guidance to the stomach as the 6.6 mm gastroscope could not pass the stricture. Biopsies of the proximal and mid esophagus showed greater than 25 intraepithelial eosinophils per high power field, consistent with eosinophilic esophagitis.

Patient was started on fluticasone and omeprazole with improvement of his dysphagia however his esophageal stricture did not significantly improve despite 12 dilations in a 10 month period with maximal caliber being 11mm. Dupilumab was started while progressively dilating and after 2 months, we noted decreased mucosal edema, absence of previously noted furrows, and more subtle narrowing in the mid esophagus. He has now sustained dilations reaching to 13 mm. He currently reports no dysphagia on Dupilumab therapy.

Discussion: Fibrostenotic phenotype EoE is challenging to treat with a high percentage of patients requiring multiple endoscopies for esophageal dilation. There are risks with esophageal dilation including esophageal perforation and anesthesia exposure. Furthermore, some patients, such as ours, do not respond to repeated esophageal dilations. Our case suggests that Dupilumab can be a promising therapy for adult patients with fibrostenotic EoE refractory to repeated dilations.



Disclosures:


Kevin Groudan, MD, John Miller, MD. P3338 - Refractory Adult Fibrostenotic Phenotype Eosinophilic Esophagitis Treated With Dupilumab, ACG 2023 Annual Scientific Meeting Abstracts. Vancouver, BC, Canada: American College of Gastroenterology.