A Systematic Review of the Risk of Perforation During Esophageal Dilation for Patients with Eosinophilic Esophagitis

Eosinophilic esophagitis (EoE) is associated with tissue remodeling that can result in esophageal mucosal fragility, and esophageal dilation for patients with EoE is known to cause painful mucosal lacerations. Clinicians have been admonished that patients with EoE may be exceptionally predisposed to perforation with esophageal dilation, a notion supported primarily by case reports. We have conducted a systematic review of literature on esophageal dilation in EoE in an attempt to better define the risk of perforation. We searched PubMed and abstracts presented at the annual scientific meetings of the American Gastroenterological Association and the American College of Gastroenterology to identify reports on esophageal dilation in EoE. We analyzed reports meeting the following criteria: (1) the diagnosis was established from esophageal biopsy specimens revealing a parts per thousand yen15 eosinophils/hpf, (2) esophageal dilation was described, (3) esophageal perforations described were the result of esophageal dilation. We identified 18 reports for inclusion in our systematic review. The studies comprised 468 patients who underwent a total of 671 endoscopic dilations. Esophageal mucosal tears were described in most cases, but there was only one perforation among the 671 dilations (0.1%). Our systematic review does not reveal an inordinate frequency of esophageal perforation from dilation in patients with EoE, and it is not clear that dilation is any more hazardous for patients with EoE than for patients with other causes of esophageal stricture. Although esophageal dilation must be performed with caution in all patients, the risk of perforation in EoE appears to have been exaggerated.