Endoscopic Diagnosis and Response Evaluation in Patients with Eosinophilic Esophagitis

Abstract

Purpose of review The aim of this review is to provide practical guidance for clinicians to support the optimal use of endoscopy in both the diagnosis and the evaluation of treatment response in patients with eosinophilic esophagitis (EoE). Recent findings The systematic and high-quality assessment and grading of EoE endoscopic features improves EoE detection. Fibrotic complications of EoE that negatively impact patients’ symptoms and quality of life can be detected and treated through endoscopy. The correlation between endoscopic features of EoE and histological activity remains challenging. However, assessment of endoscopic activity is fast and reliable in the evaluation of treatment response and, therefore, is supported by current guidelines. New modalities such as FLIP panometry and molecular markers for diagnosis and monitoring of EoE are promising, but whether they may replace endoscopy in guiding treatment of EoE needs to be ascertained. Summary Endoscopy plays a central role in EoE management, both in routine practice and in clinical trials. Endoscopy is pivotal in EoE diagnosis and response evaluation since it allows the direct assessment of endoscopic disease activity and, indirectly, the histological evaluation. Consequently, together with clinical and histological evaluation, endoscopy is rapidly becoming essential in monitoring the effectiveness of therapy in patients with EoE.

Accuracy of the Eosinophilic Esophagitis Endoscopic Reference Score in Children

“…In this study, there was good correlation between endoscopic findings suggestive of EoE and the presence of eosinophilic infiltrate and, in accordance with other studies, the presence of more than one endoscopic abnormality is strongly suggestive of EoE (12)(13)(14)(15)(17)(18)(19) . Edema, whitish exudates, and vertical lines are useful to identify EoE, and a score comprising these findings can be highly predictive of esophageal eosinophilia, particularly in children.…”

“…The studies, that showed better sensitivity of the endoscopic findings, had selected patients after PPI treatment, following the previous criteria for diagnosis of EoE that required a failed response to PPI to establish the diagnosis (13,(15)(16)(17)(18)26,29) . PPI have both anti--inflammatory and anti-secretory actions.…”

“…Therefore, it is essential to recognize whether the disease has an inflammatory or fibrostenosing pattern from its onset (23,28,31) . Early and effective diagnosis and treatment of eosinophilic esophagitis may prevent long-term complications including fibrosis and strictures that may require subsequent endoscopic intervention (11,18,19,21,31,32) .…”

“…The EoE endoscopic reference score (EREFS) was developed and validated in adults and has been demonstrated to be an adequate tool for diagnosing and assessing treatment response in children (11)(12)(13)(14)(15)(16)(17)(18)(19) . The presence of two or more endoscopic findings is more useful for diagnosis and exhibits better sensitivity and specificity (7,9,(11)(12)(13)(14)17,18) .…”

“…Inflammatory characteristics of the EREFS (edema, whitish exudates, furrows) were shown to be highly predictive for esophageal eosinophilia in children diagnosed with EoE after treatment with PPI (11,13,14) . The presence of rings, strictures, and esophageal narrowing, which are signs of disease progression, are less prevalent in children (15,(17)(18)(19)(20)(21)(22) .…”