Jul 22, 2026
Co-hosts Ryan Piansky, a patient advocate living with
eosinophilic esophagitis (EoE) and eosinophilic asthma, and Holly
Knotowicz, a speech-language pathologist living with EoE who serves
on APFED’s Health Science Advisory Council, interview Dr. Claire
Beveridge about EoE and dysphagia.
Disclaimer: The information provided in this podcast is designed to support, not replace, the relationship between listeners and their healthcare providers. Opinions, information, and recommendations shared in this podcast are not a substitute for medical advice. Decisions related to medical care should be made with your healthcare provider. Opinions and views of guests and co-hosts are their own.
Key Takeaways:
[:49] Co-host Ryan Piansky introduces this episode, brought to you thanks to the support of Education Partners AstraZeneca, GSK, Sanofi, Regeneron, and Takeda. Ryan introduces co-host Holly Knotowicz.
[1:17] Holly introduces today’s topic, research on eosinophilic esophagitis (EoE) and dysphagia.
[1:24] Holly introduces and welcomes today’s guest, Dr. Claire Beveridge, a gastroenterologist at the Cleveland Clinic. Dr. Beveridge heads the EoE Adult Clinic and the Transition from Pediatric to Adult EoE Clinic.
[1:36] Holly, a speech pathologist, says she is very excited to dive into the research Dr. Beveridge did with EoE and dysphagia. Holly asks Dr. Beveridge to share some of her background.
[1:48] Dr. Beveridge was recruited to the Cleveland Clinic about five years ago to head the EoE Center. She loves the work they have done there.
[1:57] Dr. Beveridge says it’s been nice to center everything on their EoE patients and have multidisciplinary care with speech-language pathologists, allergists, dietitians, pulmonologists, and more. It’s been a great experience.
[2:15] Dr. Beveridge says the other thing they are really proud of is having a Transition Clinic. It can be tough for patients to transition from pediatric to adult care.
[2:23] Dr. Beveridge says this is something she was inspired to do when she was finishing her training at the University of Pennsylvania, where they had been doing some of that. It was really important to her when she joined Cleveland Clinic.
[2:34] Dr. Beveridge, with her Co-director, Dr. Sophia Patel, helps patients transition from pediatric to adult care.
[2:41] Holly speaks of the challenge of transitioning from pediatric care at a multidisciplinary clinic to adult care.
[3:08] Dr. Beveridge says you can’t do any training at Northwestern without loving the esophagus. She did her residency there, got exposed to esophagology, and got to know Dr. Gonsalves and Dr. Hirano really well.
[3:33] Drs. Gonsalves and Hirano are really big names in EoE. Dr. Beveridge was fascinated by the disease. She loved the patients and wanted to help them and make them feel better. It’s a burgeoning field.
[3:48] Dr. Beveridge says that it’s only in the last few years that we have had FDA-approved medications for it, and that we have been jerry-rigging asthma medications to treat our patients.
[4:03] Dr. Beveridge says it’s really exciting to see the treatment options we can offer.
[4:10] Ryan says it’s exciting to see how EoE management has changed.
[4:16] Ryan says we see so many patients who are untreated or poorly treated for years, who have restructuring of their esophagus and present with dysphagia, or have strictures and rings leading to food impactions; the long-term effects of untreated EoE.
[4:34] Ryan says it’s exciting that now we do have better treatment options for people, right off the bat.
[4:43] Dr. Beveridge conducted some research on EoE and dysphagia and presented a poster at the 2024 Digestive Diseases Week.
[4:51] The poster was titled, “Esophageal Luminal Diameter is Associated with Dysphagia and Eosinophilic Esophagitis: Implications for Endoscopic Dilation Therapy.”
[5:11] Dr. Beveridge says dysphagia means issues with swallowing. It’s a feeling of something getting stuck or something slowly moving down. There are also subtle symptoms that can happen.
[5:31] Dr. Beveridge says patients who have had EoE for a long time become accustomed to how they swallow. Things a patient may think are normal, like needing water and taking a sip after each bite, are learned accommodating behaviors.
[5:58] Dr. Beveridge says accommodating behaviors are that you’re needing to imbibe extra water, you’re modifying how you’re eating, extra chewing, avoiding pills, avoiding other certain foods, and things like that that can be modifying factors.
[6:19] So, difficulty with swallowing, things getting stuck, slowly moving down, but also keeping in mind some of those modifying behaviors that we may end up using.
[7:23] Dr. Beveridge says her motivation was seeing patients in her clinic who were having persistent symptoms, and getting them into histological remission. The goal of treating your EoE is to get the eosinophils less than 15; close to zero is great.
[7:45] Dr. Beveridge says we have patients who, despite doing their endoscopies and taking biopsies, things look fine; they’re still having issues with swallowing. Why is that the case?
[7:58] Dr. Beveridge says in a different research paper she had done, looking at some of the predictors for that, one of them was fibrostenosis. There are also other things that can contribute, like esophageal hypervigilance and a fear of swallowing.
[8:21] If a patient has had a food impaction, it’s going to be scary to try to swallow again. Some of it is behavioral, but some of it is structural. At what luminal diameter (the size of the esophagus) is that causing a clinical problem for patients?
[8:45] A normal esophagus is 20 to 24 mm in diameter. Traditionally, around 14 to 16 mm in diameter has been when we say that patients get symptoms or they're feeling the issues with swallowing.
[9:03] Dr. Beveridge says a lot of those studies have never been done specifically for EoE patients.
[9:08] Dr. Beveridge wanted to know, if we exclude cancer, if we exclude acid reflux, and all of these other things, and just look at our EoE patients, what size of the esophagus are we looking at?
[9:20] Dr. Beveridge explained they specifically looked at patients whose histology was under control and then compared those who continued to experience symptoms with those who did not. The goal was to determine the histologic threshold at which patients begin to experience dysphagia.
[9:54] Dr. Beveridge says they saw this threshold at 16 mm (1.6 cm). That’s still quite the difference from a normal esophagus of 20 to 24.
[10:08] Dr. Beveridge says our esophagus can definitely handle being smaller, but then, once you get to that 16 mm, for a lot of patients, it really does cause that feeling of things getting stuck or slowly moving down.
[10:20] Holly says what’s cool about the retrospective data Dr. Beveridge looked at, and the parameters she placed in the research, is that when a patient goes in for an endoscopy, the doctor can measure and say maybe this is why dysphagia is going on.
[10:48] Holly finds that adult patients with food impactions are scared to eat the same food again. She loves having this data to share with patients and say, let’s look at what your esophagus measures at. Let’s do a smaller bite. Let’s add a dip and liquid.
[11:12] Holly says data can push so much progress. Holly, having multiple chronic illnesses, loves when doctors can say, this is going to be safe. This is the mode that we’re going to go with.
[11:30] Dr. Beveridge says in the retrospective study, they were looking at stuff that had already been done. We decided from here to assess patients more prospectively. All of this was based on chart review from when the note said symptoms or no symptoms.
[11:53] Dr. Beveridge says when she started this EoE clinic at the Cleveland Clinic, part of it was to standardize better how we were collecting data from patients to understand their symptoms.
[12:07] Dr. Beveridge has a standardized questionnaire for patients to understand if they are having heartburn and difficulty with swallowing, so she can know that at each point of their endoscopy.
[12:18] Dr. Beveridge says it will be nice, hopefully in the future, when she can give a little more detail and depth in terms of assessing this more prospectively and seeing if that same number holds up or if she needs to tweak it a little bit.
[12:34] Holly thinks it’s fascinating. Numbers give us so much information, to know if my mm is this versus this, the next time, or during allergy season or not.
[12:53] Ryan says it’s cool that you’re able to look back at existing patient records and identify this information. Now we have that 16 mm number in mind to say maybe this is where we’ll start to see increased risk of dysphagia in these patients.
[13:28] Dr. Beveridge says, how we had to do it retrospectively was based on the endoscopist estimating what the size is. Gastroenterologists recognize they’re not always the best at estimating the size of the esophagus.
[13:50] Dr. Beveridge says, if your endoscope could not pass through, or it was snugly passing through, you know the diameter of the endoscope. If a dilation was done, at what size dilation do we start to see a disruption?
[14:19] Dr. Beveridge says, the goal of a dilation is to get a disruption because there’s scar tissue we want to break open. A patient might think disruption means a perforation or something more scary, but that is the goal. We want to break open that scar tissue.
[14:42] Dr. Beveridge says, once we see that scar tissue break open a little bit, then we can estimate what the diameter is, based on the size dilator we used.
[15:10] Dr. Beveridge says for adults, we use a standard adult upper endoscope, and that’s about 13 mm. The ones we use for kids are about 6 mm.
[15:35] Dr. Beveridge says the adult endoscope is around 13 mm, and it’s around 14 to 16 mm when we start to see the symptoms.
[16:07] Dr. Beveridge says there are two main types of dilation that we do. One is the Savary dilator or wire-guided dilator, a long dilator that stretches the entire esophagus, from the mouth down to the stomach.
[17:20] Dr. Beveridge says another way of doing it is while you have the endoscope in, you thread a catheter. At the end of the endoscope, there’s a balloon. You fill the balloon with saline up to different sizes. Typically, they go up by 3 mm, so 12 to 15 mm.
[18:01] Dr. Beveridge says the catheter balloon dilator is good for discrete strictures because the balloon isn’t going to do the entire esophagus; it’s just going to do one area of the esophagus, and you’re watching it the whole time.
[18:19] For the wire dilator, you remove the scope. You’re not able to see, so it’s important to assess ahead of time how narrow things are, so you start at a safe dilation. You go in each time to see if there’s starting to be disruption, and then you can do more.
[18:44] Holly asks if a gastroenterologist doing an upper endoscopy with sedation sees that it’s tight, would the gastroenterologist automatically do a dilation? Or, can a patient with dysphagia symptoms request to have a dilation?
[19:28] Dr. Beveridge says, right before an endoscopy, she discusses it with the patient and gets consent. She asks, even if their symptoms are good, but in the endoscopy she sees a narrowing where she would recommend a dilation, if they’re OK with that.
[20:05] Dr. Beveridge says, if they’re having issues with swallowing, often she will ask if they’re OK with her doing a dilation. If she sees a narrowing, she can focus on that area and dilate it.
[20:19] Dr. Beveridge says not everywhere in the esophagus can we see as well. The very beginning of the esophagus is challenging to see and challenging to evaluate on imaging.
[20:32] Dr. Beveridge talks about empiric dilation. You don’t see a narrowing, but you want to rule it out, so you do a dilation at a safe size, like 16 or 18 mm, to make sure you’re not missing something up high.
[20:58] Dr. Beveridge says she always talks about that with her patients. Most say, go ahead. Some patients definitely want dilation; other patients say no, they really don’t.
[21:12] Dr. Beveridge then asks the patient if there’s real narrowing that may cause a food impaction, would they want dilation then, or hold off for another day?
[21:30] Dr. Beveridge never wants to do something the patient is not comfortable with. She also doesn’t want them to need another endoscopy unnecessarily, if she can avoid that for them in the moment.
[21:46] Dr. Beveridge mentions the BougieCap used in Europe. It’s a cap you put at the end of the endoscope. You use your endoscope as the dilator. You watch the whole time. It is hard plastic that causes a nice dilation. We may see it come to the U.S.
[22:37] Dr. Beveridge speaks of the FLIP catheter, which is a catheter with a balloon that doesn’t cause dilation but distends and helps measure the diameter.
[23:33] Holly asks if Dr. Beveridge gives tips to patients on how to prepare for dilation and the recovery process.
[23:49] Dr. Beveridge had an upper endoscopy. She says there’s nothing like experience to understand it better. She didn’t have a dilation, but the biopsies caused discomfort.
[24:21] Dr. Beveridge says a lot of her patients have been through upper endoscopies, so they know how it feels. She warns them that the biopsies and dilation can cause discomfort.
[24:33] What’s challenging is that everyone is different. Some patients are going to be more hypersensitive to it, and other patients are going to say they felt nothing and they were fine.
[24:46] Dr. Beveridge says some patients need to modify their diet for a few days to avoid significant chest pain. You never want someone to have to go to the ER for significant chest pain when it will just heal over time, and there’s no perforation.
[25:12] Dr. Beveridge says other patients will be like her, eating chips and pretzels and saying they’re fine. Dr. Beveridge typically has them start with liquids, nothing too hot or too cold, and advance as tolerated.
[25:28] Dr. Beveridge says patients can always use TylenolⓇ and over-the-counter numbing agents. You’ll still have patients who will get significant discomfort. For the most part, starting with liquids has worked for Dr. Beveridge’s patients.
[25:44] Holly recommends over-the-counter when her patients call, after she talks to their GI. Holly says after she has an endoscopy, she starts on liquids and shakes. On day three, she’s fine. Holly says individualized care is amazing. We all are different.
[26:14] In the pediatric setting, the parents get the counseling, and they have not had sedation, but on the adult side, you’re talking with the patient, who had sedation. Sometimes they don’t remember.
[26:40] Dr. Beveridge says when possible, she waits for family members to come back and tells them they’re going to have to “be the memory” because the patient probably won’t remember this conversation.
[26:55] If a patient says no, they don’t want them to come back and hear about it, always respect that. But Dr. Beveridge always tells them, you may not remember what we say.
[27:30] Ryan asks about data on how many times someone may need dilations. Dr. Beveridge says it comes down to the patient, but the biggest issue can be uncontrolled inflammation.
[27:44] Dr. Beveridge says if a patient’s EoE is not controlled, inflammation leads to continued scarring down. That’s why we talk about dilation as being an adjunctive measure, but not a treatment for EoE. It doesn’t do anything for the inflammation.
[28:03] Dr. Beveridge says she has patients who ask why she can’t just do a dilation every now and then. Dr. Beveridge considers dilation to be safe when needed, but if you can avoid it, that would be nicer for everyone.
[28:21] Dr. Beveridge says there’s no great data on whether you only need one, or whether you're going to need 10, but one big theme is just: have we gotten your inflammation under control? That’s also true for other conditions, such as acid reflux.
[28:45] Holly wasn’t diagnosed until she was in her mid-twenties, and she had several upper endoscopies as a teenager and college student to dilate her, to help the situation.
[29:17] Holly says she had to get more endoscopies to figure out her weird food triggers that are not typical for everybody, so even if she’s treated, she still has inflammation. That’s why she had so many upper endoscopies.
[29:30] Ryan talks about underlying issues causing inflammation. Dilation is not treating those underlying causes. It’s just helping with one symptom of this dysphagia, by expanding the esophagus.
[29:50] Ryan asks, What changes in symptoms should patients expect after the dilation? Dr. Beveridge says, ideally, if there’s been a stricture, you’re going to start to feel like your swallowing is better. You can get pills and food down better.
[30:07] Dr. Beveridge says, immediately post-dilation, sometimes people feel a little bit worse. Everything you swallow may be uncomfortable for you. But if it’s been a successful dilation, hopefully, you’re going to feel that things are going down better.
[30:40] Holly says she is so grateful that Dr. Beveridge looked into this, and hopefully, there will be a new protocol in the future. Holly asks what other key takeaways from this research may interest Dr. Beveridge in researching something further.
[31:02] Dr. Beveridge says, making sure that we’re not missing scar tissue is big and important. One thing that we’re trying to look at with our Pediatric GI colleagues is what threshold we should be looking at for the pediatric patient population.
[31:19] Dr. Beveridge says a pediatric patient’s esophagus is a different size than an adult patient's. Understandably, we are more cautious when doing a dilation in the pediatric patient population than we are with adults.
[31:34] Dr. Beveridge may recommend empiric dilation for an adult but will feel more cautious about that with pediatric patients than with adult patients. Understanding what that threshold should be for the pediatrics is going to be really interesting.
[31:57] Dr. Beveridge says the diameter threshold we discussed is going to be important to know about, but everyone is different. You may have a diameter of 14 mm, you feel fine, and you don’t want a dilation; you can accommodate OK. That’s reasonable.
[32:15] Dr. Beveridge says she has had patients who get up to 18 mm, and that helps them, but they need a little bit more. If someone needs more of a dilation, we do that. Yes, have a threshold to assess, but always assess for what’s personal for your patient.
[33:04] Dr. Beveridge says not just to assess the luminal diameter, but a thing that is helpful for gastroenterologists to know will be if there are other factors at play. As in her study of dysphagia predictors, anxiety, depression, and hypervigilance can play roles.
[33:37] Dr. Beveridge has patients who have to have a critical narrowing for them to finally feel an issue. Other patients, if they have the slightest of narrowing, are feeling something. Some patients are just more vigilant of what’s happening in their esophagus.
[34:07] Dr. Beveridge says there’s definitely a role for asking if your anxiety is under control. If there’s feedback in the nerves, should we ask your GI Psychologist to be involved in terms of CBT for your esophagus? Take a look at everything.
[34:27] Dr. Beveridge says another part of the study they looked at was: are there different thresholds of eosinophils that we should be looking at? Is it just less than 15, or do some patients need it to be lower? Less than six? Less than 10?
[34:43] Dr. Beveridge says look at it as a whole for your patient.
[34:53] Dr. Beveridge says next, she will be working on a very long-term project: Can we identify a non-invasive method of screening a patient, diagnosing a patient for EoE, or monitoring a response to therapy?
[35:13] Dr. Beveridge has looked at transnasal endoscopy, which is put into this category of minimally invasive. It’s still invasive; you’re putting a scope through someone’s nose, but it doesn’t require sedation, which is a nice thing for some patients.
[35:29] There’s the EnteroTrack, which started in Colorado. A patient swallows a string, and it stays in their esophagus for an hour, and we look at the proteins to see if things are active or not active.
[35:45] Dr. Beveridge is also looking at the breath metabolome. If we breathe into a bag and take a look at all the volatile organic compounds that are in our breath, can we find a signature related to EoE?
[36:01] It’s assessing about 100 different compounds, not looking at one in particular, but how the whole thing looks. What signature is there, based on looking at all the compounds?
[36:15] Dr. Beveridge presented some of that data at DDW and has a grant from the ACG to look at this and assess patients with and without EoE.
[36:33] Dr. Beveridge says further, doing longitudinal data of looking at patients once they’ve gotten into remission on treatment and seeing, do we then see a signature change?
[36:47] Dr. Beveridge says no one is under any illusion that endoscopies are going away. They will always be part of what we do in gastroenterology, but there are limitations: sedation, a full day away from work, nothing by mouth, and a driver, etc.
[37:04] If there are alternatives to help supplement that, it would be nice. One of the barriers for patients doing diet elimination is the number of endoscopies that are required. If there’s a way to assess by breath if a food is a trigger, that would be good.
[37:32] Dr. Beveridge says that’s the big thing she’s looking at, but it will take years. It’s not going to be a quick, easy one, but it’s very interesting to take a look at.
[37:45] Holly speaks of how much treatment has changed since she was diagnosed. She has done all the scopes. She says this sounds amazing. She loves that people like Dr. Beveridge are thinking of how to make testing less invasive and more comfortable.
[38:12] Dr. Beveridge says another thing she is excited about is the transition of care. She recently did a survey and is analyzing the data to assess what the barrier is from the physician perspective in terms of helping our patients transition.
[38:40] Dr. Beveridge is also looking at doing a nice multi-center consensus to help this as well, led by Dr. Sophia Patel and Dr. Emily McGowan, who are fantastic in the EoE world, looking to see how we can make this better for our patients.
[38:58] Ryan says, with so much interesting work coming up, we’ll have to have you back to chat about some of these additional projects. Everyone is super interested in less invasive stuff and better treatment pathways. Transition of care is an important part of that.
[39:11] Ryan appreciates Dr. Beveridge for joining the conversation and hopes to have her back on another episode so we can learn more about EoE and these different future research endeavors.
[39:20] For our listeners who would like to learn more about EoE today, you can visit apfed.org/EoE and check out the links in the show notes below.
[39:27] If you’re looking to find specialists who treat
eosinophilic disorders, we encourage you to use APFED’s Specialist
Finder, available at apfed.org/specialist.
[39:36] If you’d like to connect with others impacted by eosinophilic diseases, please join APFED’s online community on the Inspire Network at apfed.org/connections.
[39:46] If you have personally been impacted by eosinophilic disorders and are interested in sharing your experience, please check out apfed.org/shareyourstory.
[39:55] Ryan thanks Dr. Beveridge for joining us. This was a fun conversation and really insightful. Holly thanks APFED’s Education Partners AstraZeneca, GSK, Sanofi, Regeneron, and Takeda for supporting this episode.
Mentioned in This Episode:
APFED on YouTube, Twitter, Facebook, Pinterest, Instagram
Real Talk: Eosinophilic Diseases Podcast
Education Partners: This episode of APFED’s podcast is brought to you thanks to the support of AstraZeneca, GSK, Sanofi, Regeneron, and Takeda.
Tweetables (Edited):
“I have loved the work that we’ve done [at the Cleveland Clinic]. It’s been really nice to center everything on our EoE patients and have nice multidisciplinary care with speech-language pathologists, allergists, dietitians, pulmonologists, and everyone.” — Claire Beveridge, MD
“It’s a little crazy to think that it’s only in the last few years that we have had FDA-approved medications for [EoE], and that we have been jerry-rigging asthma medications to treat our patients.” — Claire Beveridge, MD
“On the whole, dysphagia means issues with swallowing. … It’s a feeling of something getting stuck or something slowly moving down. There are also subtle symptoms that can happen.” — Claire Beveridge, MD
“The goal of a dilation is to get a disruption because there’s scar tissue we want to break open.” — Claire Beveridge, MD
“I am looking at the breath metabolome. If we breathe into a bag and take a look at all the volatile organic compounds that are in our breath, can we find a signature related to EoE?” — Claire Beveridge, MD
Guest Bio:
Claire Beveridge, MD, is a Staff Member in the Department of
Gastroenterology and Hepatology and heads the Eosinophilic
Esophagitis (EoE) adult clinic as well as the transition pediatric
to adult EoE clinic. Dr. Beveridge's specialty interests include:
EoE, Achalasia, Barrett’s esophagus, GERD, esophageal swallowing
disorders, and esophageal motility disorders.