SUMMARY
Symptoms of esophageal dysfunction such as food impaction are consistent with, but not diagnostic for eosinophilic esophagitis (EoE) without obtaining histology. We conducted a retrospective study to characterize patients with food impaction at a tertiary center. We hypothesized that many patients with food impaction may be lost to follow-up and that many have features suggestive of EoE. Adult patients presenting to the emergency department with esophageal food impaction were identified from an endoscopic database. Electronic medical records were manually abstracted. We examined associations between demographics, comorbid conditions, and follow-up with biopsy findings. Of 220 patients who presented to the emergency department for food impaction, 74.1% were men. Adequate follow-up was not documented in 120 (54.5%). Those lost to follow-up did not differ significantly by gender, age at symptom onset, or distance from hospital compared to those with follow-up. Esophageal biopsies were obtained in 158 (71.8%), and those with ≥15 eos/HPF were more likely to be lost to follow-up than those with <15 eos/HPF (52.8% vs. 34.8%, P < 0.05). Of those never biopsied, 79.0% were lost to follow-up and had intermediate proportions of males, food allergy, and asthma when compared to those with and without eosinophilic inflammation. Patients with food impaction commonly have EoE but are often lost to follow-up. Among those never biopsied, demographic and clinical features suggest that many may have undiagnosed EoE. Strategies for increasing use of biopsies in patients with food impaction and improving follow-up are needed to diagnose and manage EoE.
Keywords: biopsy, diagnosis, dysphagia, emergency, follow-up, impaction
INTRODUCTION
Eosinophilic esophagitis (EoE) is a chronic, immune, and allergy-mediated disorder that commonly presents with symptoms of dysphagia and food impaction in adults. Prior literature estimates that EoE is diagnosed in up to 23% of patients undergoing
endoscopy for dysphagia and up to half of those with food impaction.1-8 Although these are characteristic symptoms, neither dysphagia nor food impaction is diagnostic for EoE and histology demonstrating eosinophilic inflammation or ≥15 eosinophils per high power field (eos/HPF) is also required for diagnosis.9
Esophageal food impaction is considered a gastrointestinal emergency requiring urgent endoscopic therapy and may be due to eosinophilic esophagitis, strictures or rings, motility disorders, or a malignancy. Although this clinical presentation may represent EoE, esophageal biopsies are often not performed at the time of the impaction and a diagnosis of EoE requires additional repeat outpatient endoscopy with biopsies, a possible barrier to appropriate follow-up of patient care.10,11
The aim of this study is to characterize patients who presented to our tertiary care center emergently with food impaction and identify factors associated with patient lost to follow-up after endoscopy. We hypothesized that despite efforts to arrange appropriate outpatient care after urgent endoscopy, a proportion of these patients are lost to follow-up without an adequate diagnosis or disease management plan for EoE.
METHODS
Subjects
We conducted a retrospective study of patients with esophageal food impaction treated endoscopically between January 2000 and June 2017. Cases were identified from an endoscopic database of patients with food or foreign body found within the esophagus and confirmed by electronic medical record review. Cases were then limited to those who underwent endoscopy in the emergency department. Demographic information, presenting symptoms, dates of endoscopy, and any subsequent follow-up were abstracted from the electronic medical record for each patient. For each endoscopy, the indication for procedure, therapy for disease management, endoscopic scoring of disease, and histology were also collected. Patients who presented with an esophageal malignancy or palliative stenting were excluded. This study was reviewed by the Institutional Review Board of the University of Michigan School of Medicine (HUM00129506) and approved by the Medical Procedures Unit Quality Assessment committee.
Outpatient follow-up
Adequate outpatient follow-up was defined by contact with a University of Michigan gastroenterologist in the outpatient clinic, telephone call, or detailed letter, or planned endoscopy with potential biopsies to workup the etiology of the food impaction within one year. Lost to follow-up was defined by inadequate workup for the food impaction within one year.
Analysis
Associations were analyzed using the Chi-squared and Student's t-test. Data management and analysis were performed using the Stata 15 (StataCorp, College Station, TX). P-value < 0.05 was considered significant.
RESULTS
Patient characteristics
Four hundred and thirteen patients were identified with endoscopic findings of food or foreign body within the esophagus. Of these, 228 presented to the emergency department and 8 were excluded for indications including 6 patients with esophageal or gastric cardia malignancy and 2 with foreign body ingestion (coin and bottle cap). A total of 220 patients who underwent a total of 552 upper endoscopies were included in our analysis. Of these, 259 procedures were performed urgently in the emergency department. The majority (74.1%, n = 163) of patients were men, and 83 (37.7%) had a prior diagnosis of gastroesophageal reflux disease (GERD). The final diagnosis was EoE in 59 (26.8%) and achalasia in 5 (2.3%). While most patients only presented with an emergent food impaction once, 29 (13.2%) had two or more such encounters. Of these patients with recurrent food impactions, 12 (41.4%) had a final diagnosis of EoE.
Food impaction and esophageal biopsies
Biopsies were obtained in only 89 (34.4%) of endoscopies performed at the time of food impaction or 84 (38.2%) total patients. In total, esophageal biopsies were obtained in 158 (71.5%) patients either on index or follow-up endoscopy. Among those who underwent esophageal biopsies on index or follow up endoscopy, 89 (40.5%) had ≥15 eos/HPF. We compared the characteristics of the three groups by biopsy status (never biopsied, ≥15 eos/HPF, and <15 eos/HPF). Compared to patients with <15 eos/HPF, those with ≥15 eos/HPF were more likely to be male or younger at the time of symptom onset, more likely to have food allergies, allergic rhinitis, and asthma, and less likely to have GERD (Table 1).
Table 1.
Patient characteristics by esophageal biopsy status
| <15 Eos/HPF N = 69 | Never biopsied N = 62 | ≥15 Eos/HPF N = 89 | |
|---|---|---|---|
| Male | 42 (60.9%)† | 45 (72.6%)‡ | 76 (85.4%)†‡ |
| Age of symptom onset (years) | Mean 51.2, SD 18.0† | Mean 53.4, SD 21.6‡ | Mean 37.0, SD 16.3†‡ |
| History of eczema | 2 (2.9%) | 2 (3.2%) | 4 (4.5%) |
| History of food allergy | 2 (2.9%)† | 5 (8.1%) | 15 (16.9%)† |
| History of allergic rhinitis | 15 (21.7%)† | 8 (12.79%)‡ | 32 (36.0%)†‡ |
| History of asthma | 3 (4.4%)†§ | 9 (14.5%)§ | 24 (27.0%)† |
| History of GERD | 34 (49.3%)†§ | 20 (32.3%)§ | 29 (32.6%)† |
| Adequate follow-up | 45 (65.2%)†§ | 13 (21.0%)§‡ | 42 (47.2%)†‡ |
Chi-square and two-sample Student t test were used to assess differences between groups.
† P < 0.05 between <15 Eos/HPF and ≥15 Eos/HPF;
‡ P < 0.05 between ≥15 Eos/HPF and never biopsied;
§ P < 0.05 between < 15 Eos/HFP and never biopsied.
Eos, eosinophils; HPF, high power field; SD, standard deviation.
Those never biopsied demonstrated intermediate proportions of male gender, age of symptom onset, history of food allergy, eczema, and asthma compared to those with ≥ or <15 eos/HPF (Table 1, Fig. 1). Those not biopsied were also less likely to have a diagnosis of GERD than those with <15 eos/HPF.
Fig. 1.
Age of symptom onset by esophageal biopsy status. Histogram of age of onset of symptoms for each of 3 groups: <15 eosinophils/high power field, never biopsied, and ≥15 eosinophils/high power field. Those with eosinophil-rich esophagitis had a younger distribution than those without eosinophil-rich esophagitis. Those never biopsied had a uniform distribution of age of onset.
Follow-up after food impaction
Among all patients who presented emergently for food impaction, only 45.5% (100) had adequate outpatient follow-up within one year to determine the underlying etiology of the obstruction. Those who had a primary care provider within the university healthcare system were more likely to have adequate follow-up compared to those who did not (71.0% vs. 29.0%, P < 0.05). Those lost to follow-up did not differ significantly by gender, age of symptom onset, or distance lived from the hospital when compared to those with adequate follow-up. Having esophageal biopsies performed at the time of urgent endoscopy did not significantly affect follow-up (44.0% vs. 33.3%, P = 0.07, Table 2). Those with ≥15 eos/HPF were less likely to have adequate follow-up (47.2% vs. 65.2%, P < 0.05, Table 1) compared with those with <15 eos/HPF.
Table 2.
Factors based on follow-up after emergent endoscopy for food impaction
| Adequate follow-up | Lost to follow-up | |
|---|---|---|
| (N = 100) | (N = 120) | |
| Male gender | 71 (71.0%) | 92 (76.7%) |
| Age of symptom onset (years) | Mean 46.5, SD 19.3 | Mean 45.7, SD 20.4 |
| University PCP | 71 (71.0%)† | 49 (40.8%)† |
| Distance lived from hospital (miles) | Mean 89.6, SD 307.7 | Mean 127.6, SD 343.1 |
| Biopsy done at time of impaction | 44 (44.0%) | 40 (33.3%) |
Chi-square and 2-sample Student t test were used to assess differences between groups.
† P < 0.05 between adequate follow-up and lost to follow-up.
PCP, primary care provider, SD, standard deviation.
DISCUSSION
We found that patients who present to our tertiary center with food impaction requiring emergent endoscopy rarely have esophageal biopsies performed at that time. In those who do undergo biopsy, many have eosinophil-rich esophagitis (≥15 eos/HPF) and likely EoE, but are often lost to follow-up. Patients who are never biopsied frequently have demographic and comorbid features which point toward a diagnosis of EoE, suggesting underdiagnosis in this population. Although the awareness for and prevalence of EoE has increased over the last decade, the impact of esophageal food impaction on the diagnosis of EoE is unknown. In a retrospective study of similar esophageal foreign body impactions, Sperry et al. demonstrated that although the prevalence of food impaction increased over the six-year study period, the rate of biopsies performed was less than 30%, similar to our experience at the University of Michigan and prior reports.6 Without clear clinical guidelines on the management of esophageal food impactions, variations in practice patterns exist and likely result in missed opportunities to diagnose and manage EoE. A recent survey study by Hiremath et al. showed that only 34% of surveyed pediatric and adult gastroenterologists always obtain biopsies at the time of endoscopy for food impaction, a mere 2% reported routinely following patients after food impaction, and only 17% did so if esophageal biopsies were abnormal. In that provider survey, only 41% indicated performing follow-up endoscopy after food impaction.10 Our follow-up after endoscopy rates did not significantly differ by whether biopsies were performed at the time of food impaction, pointing to the need for additional postprocedural strategies to encourage continuity of care. Such strategies might include telephone follow-up by the gastroenterology provider and endoscopy unit staff, mailed letter sent to both the patient and primary care provider, or an automated reminder within a few months after the event.
Our study is unique in characterizing the rate of follow-up after food impaction with a focus on those never biopsied. Representing more than one quarter of patients requiring emergent endoscopy for food impaction, those never biopsied (either at the index or a subsequent endoscopy) have demographic and comorbid features suggesting undiagnosed EoE. Our data did not show significant differences in adequate follow-up by gender, age of symptom onset, distance lived from the hospital, or if esophageal biopsies were performed at the time of impaction. However, those with EoE were more likely to be lost to follow-up than those without eosinophilic inflammation. This breakdown in continual care could suggest a lack of clinically significant symptoms to warrant further workup, poor adherence in this patient population, and/or healthcare system-based barriers to care. Prior work has demonstrated that inadequate follow-up is a predictor of recurrent food impactions.6,12 Nearly half of patients experiencing recurrent food impactions are diagnosed with EoE in our cohort, further affirming the need for follow-up in this population of suspected EoE.
Our study had some important limitations. As a single center study of a tertiary medical center, our results may not be generalizable to other settings. We only included urgent endoscopy cases performed in the emergency department often overnight or on weekends and may have missed cases that that were managed in the outpatient endoscopy unit. We limited the search this way to avoid including large numbers of patients with motility disorders such as achalasia found to incidentally have food present within the esophagus during elective endoscopy. Given the retrospective nature of this study, the exact reasons and barriers leading to inadequate follow-up were not clearly elucidated. Because our study is a single-center review limited to care provided at the University of Michigan, information about recurrent impactions at outside facilities was not readily available. Similarly, patients who were considered lost to follow-up at our center may have established care or workup at outside facilities.
Our study also had a number of notable strengths. First, to our knowledge, this is the only study examining follow-up rates after food impaction and risk factors for loss of follow-up, particularly in EoE patients or those suspected of having EoE. We were also able to examine a number of comorbid features associated with histologic findings in patients with food impaction.
In conclusion, this study demonstrates that esophageal biopsies are not routinely taken at the time of urgent endoscopy for food impaction. Among these cases who do undergo biopsies, EoE is frequently present but these patients are at high risk of inadequate follow-up within one year. Our findings of patients never biopsied highlight the need for clinical guidelines to encourage routine biopsies and strategies to improve follow-up in this population in order to diagnose and treat likely EoE, as well as prevent recurrent impactions. In addition to addressing provider or system-related barriers to care, future work to recapture these patients who are lost to follow-up without biopsies or EoE to outpatient care is also vital in understanding patient-related obstacles to continued care.
Specific author contributions: Study concept and design: Joy W. Chang, Joel H. Rubenstein; Data acquisition: Joy W. Chang, Samuel Olson, Ju Young Kim, Russell Dolan, Joel Greenson; Statistical analysis: Data analysis and interpretation: Joy W. Chang; Drafting of the manuscript: Joy W. Chang; Critical revision of the manuscript: Joel Greenson, Georgiana Sanders, Joel H. Rubenstein; Study supervision: Joel H. Rubenstein.
Financial support: Joy Chang is supported by a research training award (T32DK062708) from the NIH.
Potential competing interests: None.
Contributor Information
Joy W Chang, Division of Gastroenterology, Department of Internal Medicine.
Samuel Olson, Division of Gastroenterology, Department of Internal Medicine.
Ju Young Kim, College of Literature, Science, and the Arts.
Russell Dolan, Department of Internal Medicine.
Joel Greenson, Department of Pathology.
Georgiana Sanders, Division of Allergy & Immunology, Department of Internal Medicine, University of Michigan.
Joel H Rubenstein, Veterans Affairs Center for Clinical Management Research, Ann Arbor VA Medical Center, Ann Arbor, Michigan, USA; Division of Gastroenterology, Department of Internal Medicine.
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