COMMENTARY

The Diagnosis of EoE: More Questions Than Answers

David A. Johnson, MD

Disclosures

July 21, 2011

In This Article

Author's Note: The literature on esophageal diseases has seen a profound increase in reports about eosinophilic esophagitis (EoE). This discussion focuses on 3 recent articles that highlight some of the confusion around the diagnosis of this disease.

Toward Uniformity in the Diagnosis of Eosinophilic Esophagitis (EoE): The Effect of Guidelines on Variability of Diagnostic Criteria for EoE

Sperry SL, Shaheen NJ, Dellon ES
Am J Gastroenterol. 2011;106:824-832

Study Summary

Consensus guidelines for the diagnosis and treatment of EoE were published in 2007; however, the impact of these guidelines on the diagnosis of EoE has not been evaluated. Sperry and colleagues conducted extensive searches of the literature on EoE from January 1, 2007 to June 30, 2010 from both MEDLINE and EMBASE as well as from presentations at national gastrointestinal medicine conferences. A total of 149 original reports, 99 reviews, and 165 abstracts were identified. Articles were rated as consistent with the 2007 guidelines if all 3 of the following criteria were present:

  • Symptoms of esophageal disease (eg, dysphagia, food impaction, regurgitation, heartburn, chest pain, feeding intolerance, failure to thrive, or nausea/emesis);

  • Histologic cutoff of ≥ 15 eosinophils per high-powered field (≥ 15 eos/hpf); and

  • Gastroesophageal reflux disease (GERD) was excluded as evidenced by failure of high-dose proton pump inhibitor (PPI) or normal pH monitoring of acid suppressants.

Overall, only 24% of articles explicitly stated that all 3 of these criteria were used for establishing the diagnosis of EoE. Furthermore, wide variation in the biopsy protocols was reported, with only 11% following the recommended biopsy protocol of taking samples from multiple esophageal locations, the stomach, and the duodenum.

Viewpoint

Despite the availability of consensus guidelines, which provide recommendations that aim for homogeneity in the diagnosis of EoE, most of the subsequent literature still does not conform to these guidelines. Clearly, improvement in reporting standards for establishing the diagnosis of EoE is needed. An appropriate and accurate diagnosis is critical before embarking on studies to evaluate treatment paradigms.

The study by Sperry and colleagues highlights some variance from the consensus diagnostic criteria for EoE. The diagnosis of EoE is frequently made only on the histology finding of ≥ 15 eos/hpf. A cardinal feature of EoE is the high density of eosinophilic infiltration evident in the esophagus. As more clinicians become aware of EoE (especially in adults), emphasis on esophageal biopsies for patients with symptoms suggestive of EoE will be increased, regardless of the appearance of the esophageal mucosa at the time of endoscopy.

Abstract

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