Distribution and variability of esophageal eosinophilia in patients undergoing upper endoscopy

Abstract

The variability of eosinophilic infiltrates in eosinophilic esophagitis is not well described. This study aimed to determine the distribution of esophageal eosinophilia and the utility of histologic cut-points for eosinophilic esophagitis diagnosis in subjects undergoing endoscopy. We performed a prospective study of adults undergoing outpatient endoscopy. Research protocol esophageal biopsies were obtained from all subjects. Incident cases of eosinophilic esophagitis were diagnosed per consensus guidelines. Biopsies were interpreted following a validated protocol, and maximum eosinophil counts (eosinophils per high-power field; eos/hpf) were determined. Histologic analyses were performed on a per-patient, per-biopsy, and per-hpf basis. There were 213 patients, yielding 923 esophageal biopsies with 4588 hpfs. Overall, 48 patients (23%), 165 biopsy fragments (18%), and 449 hpfs (10%) had ≥ 15 eos/hpf; most subjects had no or low levels of eosinophils. In the eosinophilic esophagitis cases, 119 biopsy fragments (63%) and 332 hpfs (36%) had ≥ 15 eos/hpf. There was a mean 104-fold difference between the lowest and highest hpf eosinophil count for the eosinophilic esophagitis patients; 85% of the biopsies from eosinophilic esophagitis cases also had at least one hpf with < 15 eos/hpf. The cut-point of 15 eos/hpf had a sensitivity of 100% and specificity of 96% for diagnosis of eosinophilic esophagitis. In conclusion, most patients have little to no esophageal eosinophilia. In patients with eosinophilic esophagitis, there was marked variability in the eosinophil counts by biopsy and by hpf within a given biopsy. Additionally, the 15 eos/hpf cut-point was highly sensitive and specific for eosinophilic esophagitis. Multiple esophageal biopsies from different locations should be obtained to optimize eosinophilic esophagitis diagnosis.

Evaluation of Histologic Cutpoints for Treatment Response in Eosinophilic Esophagitis

“…In exploring potential histologic outcome thresholds, we favor an eosinophil cut-point of <15 eos/hpf as this optimizes the tradeoffs between improved outcomes and losses in test performance. It also provides conceptual symmetry, mirroring the current diagnostic threshold of ≥15 eos/hpf, which has recently been supported by empiric data [30] . While these findings should be interpreted in the context of a retrospective study, they provide a starting point for furture investigations where the merits of this response threshold in a prospectively followed cohort of EoE, as well as the long-term outcomes and treatment options for patients failing to achieving this <15 eos/hpf, can be assessed.…”

Utility of a Noninvasive Serum Biomarker Panel for Diagnosis and Monitoring of Eosinophilic Esophagitis: A Prospective Study

“…Systematic allergy testing was not a component of this study. During endoscopy, research-protocol esophageal biopsies were obtained (two from the proximal, one from the mid, and two from the distal esophagus) to maximize EoE diagnostic sensitivity (30, 31). Gastric and duodenal biopsies were also collected for research purposes to exclude concomitant eosinophilic gastroenteritis.…”

Similarities and differences among eosinophilic esophagitis, proton-pump inhibitor-responsive esophageal eosinophilia, and reflux esophagitis: comparisons of clinical, endoscopic, and histopathological findings in Japanese patients

“…They were blinded in regard to the clinical diagnosis of the patients. The maximal numbers of eosinophils, lymphocytes, and neutrophils per HPF were determined [26][27][28]. In addition, the presence of epithelial basal cell hyperplasia, balloon cells, and dilated intercellular spaces in the middle epithelial layer (spongiosis) was evaluated.…”