Implementation of a biopsy protocol to improve detection of esophageal eosinophilia: a Danish registry-based study

Abstract

Background In the North Denmark Region (580 272 inhabitants), only 0–4 cases of possible eosinophilic esophagitis (EoE) were identified annually in 1999–2010, suggesting underdiagnosis. This study aimed to increase the diagnosis of EoE by introducing a regional biopsy protocol for patients with dysphagia. Methods In 2011, leaders of regional endoscopy units attended a consensus meeting where a biopsy protocol was proposed. The national pathology registry was used to identify patients with esophageal eosinophilic inflammation during 2007–2017. Results Discussion resulted in consensus on a protocol to take eight biopsy samples in dysphagia patients (four biopsies from 4 cm and 14 cm above the esophagogastric junction–“4–14–4 rule”) regardless of the macroscopic appearance, and to code eosinophilia systematically in the pathology registry. A pictogram showing the 4–14–4 rule was sent to all endoscopy units. The number of patients with esophageal eosinophilia detected per year increased 50-fold after the protocol was implemented in 2011 (median of 1 [interquartile range 0–3] vs. 52 [47–56]; P < 0.001), and the number of biopsy samples per patient doubled (median 4 [4–5] vs. 8 [6–9]; P < 0.04). Of 309 patients diagnosed with esophageal eosinophilia in 2007–2017, 24 % had erosive esophagitis or Barrett’s esophagus, and 74 % had EoE. Conclusions A consensus-based biopsy protocol and improved coding of eosinophilia in the pathology registry resulted in a 50-fold increase in patients diagnosed with esophageal eosinophilia/year. These patients can now receive treatment. The effort to establish the protocol and change the culture of endoscopists and pathologists was minimal.

A diagnostic delay of 10 years in the DanEoE cohort calls for focus on education ‐ a population‐based cross‐sectional study of incidence, diagnostic process and complications of eosinophilic oesophagitis in the North Denmark Region

“…DanEoE is a histopathology registry based cohort as previously described in detail. 9 It's based on the national "SNOMED" codes for topography and morphology of tissue. 10 All patients living in the NDR and for the first time having at least one biopsy coded with both the SNOMED code for esophagus mucosa (T62010) and inflammation with eosinophilia defined as 15+ � Despite the 50-fold increase in cases, the current study showed that the regions referring physicians and endoscopists lacked knowledge of EoE as patients had a mean diagnostic delay of 10 years, a total of one fifth of the patients were not treatment initially, and macroscopic signs of EoE were reported in less than half of inflamed patients.…”

“…-689 eosinophils (eos) in one high power field (hpf) (M47150) in 2007-2017 were included. 9 The index endoscopy was defined as the first endoscopy where the biopsy was sampled. In Denmark, every individual in the country is assigned a unique social security number and this is linked to the national population-based medical registries, including medical records, diagnostic codes, microbiology, biochemistry, and pathology findings.…”

“…In winter 2011 a regional consensus was made to increase detection of EoE patients as previously been described in detail. 9 The true incidence of EoE is, therefore, better reflected in the data from 2012. As the regions in Denmark were formed in 2008, it was not possible to calculate the incidence from 2007.…”

“…8 In the North Denmark Region (NDR) of 580,000 citizens the histopathology registry-based cohort DanEoE of patients with oesophageal eosinophilia documented a 50-fold increase when a standardized biopsy protocol was implemented in 2011. 9 The protocol dictated that at least eight biopsies should be sampled from all dysphagia patients with no exception. 9 Registry wise it was still not possible to divide the eosinophilia patients into EoE and other, as (1) the diagnose code for EoE was only recently instated, (2) the phenotype of a patient is still not included in the registries, and (3) overlap with gastro-oesophageal reflux disease (GORD) can be present.…”

“…9 The protocol dictated that at least eight biopsies should be sampled from all dysphagia patients with no exception. 9 Registry wise it was still not possible to divide the eosinophilia patients into EoE and other, as (1) the diagnose code for EoE was only recently instated, (2) the phenotype of a patient is still not included in the registries, and (3) overlap with gastro-oesophageal reflux disease (GORD) can be present. The solution was a detailed clinical description of a defined population-based cohort as the DanEoE cohort in order to calculate a more precise incidence of EoE in Denmark.…”