Refractory Eosinophilic Esophagitis (EOE) Management Algorithm Initial treatment with topical steroids Initial treatment with

Eosinophilic Esophagitis (EoE) - Treatment Algorithm Medical therapy: • Proton pump inhibition • Topical corticosteroids Diet therapy • Empiric elimination • Elemental formula • Allergy testing directed #EoE #Eosinophilic #Esophagitis #Treatment #Algorithm #management #gastroenterology

Eosinophilic Gastroenteritis Management Algorithm - PPI x 8 weeks - Dietary therapy with Empiric Elimination or Elemental x 6 wks - Oral or Topical Corticosteroids x 4-8 wks #EoE #Eosinophilic #Gastroenteritis #Management #Algorithm #Treatment #gastroenterology

Eosinophilic Gastroenteritis: Treatment Options Based on Severity of the Disease Mild: • Trial of PPI • Trial of topical crushed budesonide • Empiric elimination diet Moderate: • Trial of PPI + Trial of topical crushed budesonide with cromolyn • Trial of PPI with Empiric elimination diet Severe: • Trial of PPI plus • Oral corticosteroids • Elemental diet • Biologic therapy • Surgical consultation for non-healing ulcers/strictures Severe + Concern for HES: • Hematology consult for evaluation of HES • Additional diagnostic imaging such as CT scan #EoE #Eosinophilic #Gastroenteritis #Treatment #management #gastroenterology

Eosinophilic Esophagitis (EoE) - Topical Corticosteroids • Liquid - Budesonide - 1 mg PO BID - Mix with sucralose or honey to increase viscosity (1mg of drug + 5 packets of sucralose) • Powder - Fluticasone 1 mg PO BID - Can use blister packets within fluticasone diskus • Inhaled - Fluticasone 880 mcg BID - Do not inhale, do not use spacer General Considerations: - Considered off-label use, FDA approved steroid formulations for treatment of EOE are currently unavailable - Administering the second dose at bedtime increases esophageal exposure time - Avoid eating/drinking 30 minutes after use - Avoid rinsing mouth immediately following ingestion unless oral Candidiasis occurs Long-Term Maintenance: - Limited data on optimal dosage, and side effects of long-term use - Consider periodic monitoring for adrenal insufficiency and bone density until more safety data is available Gastroenterology Review @GIreview #Eosinophilic #Esophagitis #EoE #Topical #Corticosteroids #management #pharmacology

Secondary Causes of Esophageal Eosinophilia (EoE) - Differential Diagnosis • Gastroesophageal reflux disease • Eosinophilic gastrointestinal disease • Achalasia • Hypereosinophilic syndrome • Esophageal Crohn's disease • Infections (fungal, viral) • Connective tissue disorders • Autoimmune disorders • Vasculitis • Drug hypersensitivity reactions • Pill esophagitis • Stasis esophagitis • Graft versus host disease • Marfan syndrome type II • Hyper-IgE syndrome • PTEN hamartoma tumor syndrome • Netherton's syndrome • Severe atopy metabolic wasting syndrome #Eoe #esophagitis #Eosinophilic #Differential #Diagnosis #Secondary #Causes #gastroenterology

Eosinophilic Esophagitis (EoE) - Spectrum of Response Non-response: • Histology: Persistent eosinophilia, ≥ 15 eos/hpf • Symptoms: Persistent symptoms, <30% decrease in a symptom metric • Endoscopy: Persistent endoscopic findings, <30% decrease in EREFS Response: • Histology: Reduced eosinophilia, 7-14 eos/hpf 1-6 eos/hpf • Symptoms: Decreased symptoms, 30-90% decrease in a symptom metric • Endoscopy: Improved findings, EREFS score ≥2 but less than baseline Complete Normalization: • Histology: Normal biopsy, <1 eos/hpf • Symptoms: Symptom resolution, >90% decrease in a symptom metric; EEsAl score < 20 • Endoscopy: Normal esophagus, EREFS score < 2 #Eosinophilic #Esophagitis #EoE #Response #diagnosis #gastroenterology

Eosinophilic Esophagitis (EoE) - Endoscopic ReFerence Score (EREFS) Edema (Loss of vascular markings): - Grade 0: Distinct vascularity - Grade 1: Absent or decreased Rings (trachealization): - Grade 0: None - Grade 1: Mild (ridges) - Grade 2: Moderate (distinct rings) - Grade 3: Severe (Scope will not pass) Exudate (white plaques): - Grade 0: None - Grade 1: Mild (≤ 10% surface area) - Grade 2: Severe (> 10% surface area) Furrows (vertical lines): - Grade 0: None - Grade 1: Mild - Grade 2: Severe (depth) Stricture: - Grade 0: Absent - Grade 1: Present #EREFS #EoE #Eosinophilic #Esophagitis #Endoscopic #ReFerence #Score #diagnosis #classification #gastroenterology #EGD #grading

$Management of Medically Refractory Gastroparesis Gastroparesis Pathophysiology Initial Evaluation Management Medications for Medically Refractory Gastroparesis Gastric Electrical Stimulation Pylorus Directed Therapies Dr. Chaitanya$

Management of Medically Refractory Gastroparesis Gastroparesis Pathophysiology Initial Evaluation Management Medications for Medically Refractory Gastroparesis Gastric Electrical Stimulation Pylorus Directed Therapies Dr. Chaitanya Allamneni @CAllamneni via @EmoryGastroHep #Gastroparesis #Refractory #Management #Treatment #Gastroenterology

Acute Pouchitis - Management Algorithm Ciprofloxacin 500 mg/12 h or metronidazole 20 mg/kg/d x 2 weeks - Response - No Response (Chronic Refractory) #Pouchitis #Management #Algorithm #treatment #IBD #gastroenterology #Refractory

Orofacial Granulomatosis - Diagnosis and Management Algorithm Idiopathic OFG: isolated swelling of the lips, BX+ non-caseating granuloma Melkersson-Rosenthal syndrome: lip edema + fissured tongue + facial paralysis *Differential Dx: Crohn's, Sarcoidosis, TB, Foreign-body granuloma, Mycotic ulcer, Lymphoma, GPA, Syphilis, Cat-Scratch Dis. Up to 40% of children with OFG may have or develop CD Low threshold for eval. Mild Dx - Also applies to mild oral aphthous ulcers: • Elimination Diet* * • 5-ASA Mouthwash • Lidocaine pre-meals • Topical Steroids (Triamcinolone dental paste) • Intralesional Steroid Moderate-Severe DX - Moderate-Severe OFG, MRS: • Elimination Diet* * • Intralesional Steroid • Topical/Systemic Steroids • Immunomodulator • Biologic (Anti-TNF, UST) • Topical Tacrolimus • Dapsone, Clofazimine, Thalidomide Pyostomatitis Vegetans: • Rare oral manif. of IBD; UC>CD • Snail track appearance of oral mucosa • Asymptomatic or painful • Bx: eosinophilic microabscesses, • Resolve w Rx of IBD Algorithm by Dr. Waseem Ahmed @Waseem_AhmedMD #OFG #Orofacial #Granulomatosis #Diagnosis #Management #Algorithm #treatment