Adaptive Behaviors, Esophageal Anxiety, and Hypervigilance Modify the Association Between Dysphagia Perception and Histological Disease Activity in Eosinophilic Esophagitis

Introduction: Adaptive behaviors at mealtime, esophageal symptom-specific anxiety and hypervigilance 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., modified dysphagia symptom questionnaire [mDSQ], Dysphagia Symptom Score [DSS], and Esophageal Hypervigilance and Anxiety Scale). 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 patients with EoE. Esophageal anxiety and hypervigilance were significantly higher ( P = 0.03 for both), and adaptive behaviors were significantly more prevalent in histologically active EoE compared with EoE in remission (76.8% vs 25.6%, P < 0.001). As a standalone measurement, mDSQ and DSS had area under the receiver operating characteristic curve of 77.7% and 75.3% for predicting HDA. Adjustments of mDSQ and DSS based on individual Esophageal Hypervigilance and Anxiety Scale scores and adaptive behaviors at mealtime significantly improved the area under the receiver operating characteristic curve of mDSQ and DSS to 86.6% and 84.3%, respectively ( P < 0.05 for both). Discussion: Use of adaptive behaviors, higher esophageal anxiety and hypervigilance are associated with active EoE and represent clinical markers of HDA. Adaptive behaviors provide complementary clinical information that is not detected by symptoms alone. The assessment of adaptive behaviors, anxiety, and hypervigilance improves the correlation between clinical and HDA in Eo