Non‐oesophageal eosinophilic gastrointestinal diseases are undersuspected clinically and underdiagnosed pathologically

Abstract

Summary Background Non‐oesophageal gastrointestinal eosinophilic diseases (EGID) are considered rare. However, low disease awareness among clinicians and pathologists may contribute to underdiagnosis. Aims To determine how frequently requests to evaluate for EGID accompany gastrointestinal biopsies and in what proportion of suspected cases pathologists address these requests, either confirming or refuting the clinical suspicion. Methods All cases in which biopsy requisitions included an explicit suspicion of EGID were extracted from a large clinicopathologic database and manually reviewed for accuracy. The diagnoses for these cases were then analysed to determine whether clinical suspicions were confirmed, refuted or ignored. Results Eosinophilic oesophagitis (EoE) was suspected in 12.8% of 903,516 patients with biopsies and confirmed in 14.9% of them. A suspicion of eosinophilic gastritis accompanied <0.001% of 1,438,206 gastric biopsy sets and was confirmed in 11.5% of them; eosinophilic duodenitis was suspected in 0.02% of ~675,519 patients with duodenal biopsies and confirmed in 8.0% of these; eosinophilic colitis was mentioned in <0.001% of 2,504,485 patients with colonic biopsies and confirmed in 0.1% of them. Less than 3% of endoscopists mentioned non‐oesophageal EGID in the requisition, while most expressed a clinical suspicion of Barrett oesophagus, Helicobacter pylori gastritis, celiac disease and microscopic colitis (in 21.2%, 49.2%, 1% and 6.4% of the cases, respectively). Conclusions Gastroenterologists and pathologists commonly address and diagnose EoE. In contrast, both clinical suspicion and diagnosis of non‐oesophageal EGID are extremely rare. Increased clinical awareness might result in a better understanding of the epidemiology and improved diagnosis of these still elusive conditions.

Eosinophilic Gastritis and Enteritis Are Increased in Families With Eosinophilic Esophagitis

“…We also note that distal EGIDs often go undiagnosed and coded as abdominal pain, irritable bowel, or dyspepsia if biopsies and eosinophil quantification are not performed. Diagnosis of concurrent EGIDs (i.e., EC with EoE, EGE with EC or EoE) could be missed if endoscopies or appropriate biopsies are not performed or interpreted (19,20). Presently, there is ongoing work to define the evaluation and diagnosis of EG/EGE and EC, which may increase detection and diagnosis of distal EGIDs in the future (3).…”

Editorial: the CTA on EGIDs—author's reply

“…A few decades ago, it was not uncommon for surgeons to send a specimen for frozen section examination with no clinical information and the not‐always‐implicit message “you tell me what this is.” It has now become clear that this swaggering attitude is unhelpful: most clinicians accompany their biopsies with concise but relevant information, and pathologists value and attempt to act on these collegial communications. We believe that the main reason why our study shows a dearth of mentions of non‐oesophageal EGID is not the gastroenterologists' reluctance to communicate their suspicions (they do, and quite often, for disease they know), but a pervasive lack of familiarity with these conditions, their manifestations and their management 4 . Pathologists, even those experienced in gastrointestinal diseases, are astonishingly uninformed about non‐oesophageal EGIDs and doggedly uninterested in evaluating eosinophilic infiltrates in the digestive tract 5 …”

Review article: Emerging insights into the epidemiology, pathophysiology, diagnostic and therapeutic aspects of eosinophilic oesophagitis and other eosinophilic gastrointestinal diseases

“…When compared to patients with EoE, those with non‐EoE EGIDs reported more frequent symptoms as well as more extra‐luminal symptoms such as fatigue or muscle or joint pain 44 . Aside from widespread symptomatology, other diagnostic challenges include a lack of clinical awareness by clinicians and under recognition of eosinophils on histologic evaluation 105–107 …”