The Diagnosis of EoE: More Questions Than Answers

David A. Johnson, MD


July 21, 2011

In This Article

Esophageal Eosinophilic Infiltration Responds to Proton Pump Inhibition in Most Adults

Molina-Infante J, Ferrando-Lamana L, Ripoll C, et al
Clin Gastroenterol Hepatol. 2011;9:110-117

Study Summary

Molina-Infante and coworkers culled data from a cohort of 712 adults with upper gastrointestinal symptoms who had endoscopic biopsies taken from the proximal and midesophagus at the time of endoscopy. Within this group, they found 35 patients who had esophageal eosinophilia (≥ 15 eos/hpf) and 9 who met the consensus document's diagnostic criteria for EoE. All patients were treated with rabeprazole, 20 mg twice daily for 2 months, and then reassessed. Clinicopathologic remission was evident in 75% of patients on PPI therapy. Whereas the clinical and endoscopic features were highly predictive of EoE, they were not predictive of response to PPI therapy. Resolution of esophageal eosinophilic infiltration was evident in 33% of patients who had normal pH monitoring and 88% of those with abnormal values. When clinical and endoscopic findings were compatible with EoE, 50% of patients achieved remission.


This study suggests that in patients with histologic features consistent with EoE (≥ 15 eos/hpf), a significant proportion will respond to PPI therapy. To date, no specific biomarkers can differentiate GERD from EoE. Eosinophilic infiltration is a histologic feature of GERD, but typically this is < 7 eos/hpf. By this definition, many patients in the current study would not meet all the diagnostic criteria for EoE, given the response to PPI and the abnormal pH baseline of some patients. Conceivably, the PPI response in these patients is related to GERD or perhaps a PPI-mediated effect on an allergic pattern of esophageal inflammation in patients with true EoE. These data suggest that EoE may be diagnosed more frequently if only the initial histology is considered. Clinicians should use PPI therapy as the logical initial therapy with sequential assessments of response, and establishment of the correct final diagnosis, before embarking on more complicated pharmacologic therapies.

The studies by Sperry and colleagues and Molina-Infante and colleagues illustrate the variance and confusion related to the application of histologic criteria in the diagnosis of EoE. EoE has hallmark endoscopic features, but these are not part of the diagnostic criteria established by the consensus guidelines. Several reports have inferred that endoscopists frequently miss the initial diagnosis of EoE, the diagnosis being established subsequently only as a result of a re-evaluation (frequently by another gastroenterologist) for continued symptoms. The endoscopic appearance of EoE includes concentric mucosal rings with linear furrows or mucosal whitish plaques or nodules. No studies to date have evaluated the reliability and accuracy of these endoscopic findings.



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