Clinical features and time trends associated with an endoscopically normal esophagus in active eosinophilic esophagitis

Abstract

Background and Aims: A proportion of patients with active eosinophilic esophagitis (EoE) have a normal appearing esophagus on endoscopy (EGD). We aimed to determine associations between baseline clinical features and the endoscopically normal esophagus in EoE as well as time trends in reporting. Methods: In this retrospective study of active EoE cases from 2002-2018, patients with and without esophageal endoscopic abnormalities were compared. Multivariable logistic regression identified independent predictors of a normal EGD. The proportion of patients with a normal EGD was determined per year and before and after introduction of the first EoE guidelines and EoE Endoscopic Reference Score (EREFS). Results: Of 878 EoE patients, 101 (11.5%) had an endoscopically normal esophagus. They were younger (8.3 vs. 25.4 years), had shorter symptom duration before diagnosis (median 2.8 vs. 5.0 yrs), less likely to have dysphagia (40% vs. 76%) and food impaction (8% vs. 33%), and more likely to have abdominal pain (37% vs. 19%) (p<0.01 for all). On multivariable logistic regression, independent predictors of a normal esophagus were younger age (OR=0.96, 95% CI:0.94-0.98), abdominal pain (OR=2.03, 1.13-3.67), and lack of dysphagia (OR=0.49, 0.26-0.93). The proportion of patients with a normal esophagus decreased from 21% before the first EoE guidelines to 7% (p<0.01) after introduction of EREFS. Conclusions: An endoscopically normal esophagus is seen in ~10% of active EoE patients and should not preclude biopsies. Younger age, abdominal pain, and lack of dysphagia are independent predictors. The proportion of normal EGDs decreased over time, suggesting improved recognition of endoscopic findings.

Determination of a treatment response threshold for the Eosinophilic Esophagitis Endoscopic Reference Score

“…On endoscopy, typical features of EoE include esophageal rings, white plaques or exudates, decreased vascularity or edema, linear furrows, strictures, narrowing, and crepe-paper mucosa [9]. While these endoscopic findings of EoE are not formally part of the diagnostic criteria and they are not completely specific, they remain widely prevalent and recognized as hallmark features of the condition [3,10]. The EoE Endoscopic Reference Score (EREFS) was developed and validated to measure the severity of five key endoscopic features of EoE: edema, rings, exudates, furrows, and stricture [11][12][13][14][15][16][17][18].…”

“…On endoscopy, typical features of EoE include esophageal rings, white plaques or exudates, decreased vascularity or edema, linear furrows, strictures, narrowing, and crepe-paper mucosa 9 . While these endoscopic findings of EoE are not formally part of the diagnostic criteria and they are not completely specific, they remain widely prevalent and recognized as hallmark features of the condition 3 10 .…”

Dilation-predominant approach versus routine care in patients with difficult-to-treat eosinophilic esophagitis: a retrospective comparison

“…This was a retrospective cohort study using the University of North Carolina (UNC) EoE clinicopathologic database through 2019. The development and characteristics of the database have been reported previously [23,24]. All study participants were patients with an incident diagnosis of EoE who met consensus diagnostic guidelines at the time of diagnosis [14], including symptoms of esophageal dysfunction, ≥ 15 eosinophils per high-power field (eos/hpf), and exclusion of competing causes of eosinophilia, and in whom esophageal dilation was performed.…”

An artificial intelligence algorithm is highly accurate for detecting endoscopic features of eosinophilic esophagitis

“…The EoE Endoscopic Reference Score (EREFS), based on the endoscopic features described above, has improved the recognition, reporting, and classification of EoE 7 , 9 , 10 but is still not used as a standard tool in many settings 11 . For enhanced detection of EoE, Artificial Intelligence (AI) with deep learning (DL) could be an additional diagnostic option.…”

“…While the presence of these morphological changes is not required for diagnosis, they are supportive and prompt the biopsies necessary for histopathological confirmation 5 . However, the endoscopic features of EoE may be missed, either because physicians are not familiar with them or the morphologic changes are too subtle 7 , 8 .…”