Adaptive behaviors, esophageal anxiety and hypervigilance modify the association between dysphagia perception and histological disease activity in eosinophilic esophagitis

Background aims: Esophageal symptom-specific anxiety, hypervigilance, and adaptive behaviors at mealtime may affect dysphagia reporting in patients with eosinophilic esophagitis (EoE) but this has not been investigated. Moreover, the relationship between such confounding factors and histological disease activity (HDA) is unclear. Methods: This was a prospective study on adults with EoE. Dysphagia, anxiety, and hypervigilance were assessed using specific questionnaires (i.e., mDSQ, DSS, and EHAS). Adaptive behaviors were assessed using the Pisa EoE Adaptation Questionnaire. Appropriate statistics was used to investigate correlation between dysphagia, anxiety, hypervigilance, adaptive behaviors and HDA. Results: Ninety-five patients were included. Esophageal anxiety, hypervigilance, and use of adaptive behaviors were found in about 50% of EoE patients. Esophageal anxiety and hypervigilance were significantly higher (p=0.03 for both) and adaptive behaviors were significantly more prevalent in histologically active EoE compared to EoE in remission (76.8% vs 25.6%, p<0.001). As a standalone measurement, mDSQ and DSS had AUROC of 77.7% and 75.3% for predicting HDA. Adjustments of mDSQ and DSS based on individual EHAS scores and adaptive behaviors at mealtime significantly improved the AUROC of mDSQ and DSS to 86.6% and 84.3%, respectively (p<0.05 for both). Conclusions: Higher esophageal anxiety, hypervigilance and use of adaptive behaviors are associated with active EoE and represent clinical markers of HDA. Adaptive behaviours provide complementary clinical information that is not detected by symptoms alone. The assessment of anxiety, hypervigilance, and adaptive behaviors improves the correlation between clinical and HDA in EoE.