Quantification of Mucosal Eosinophils for the Histopathologic Diagnosis of Eosinophilic Gastritis and Duodenitis

Abstract

Eosinophilic gastrointestinal diseases, specifically eosinophilic gastritis and duodenitis, are chronic inflammatory conditions characterized by persistent gastrointestinal (GI) symptoms and elevated levels of activated eosinophils in the GI tract. Both clinical and endoscopic findings are nonspecific, no clinical or histopathologic diagnostic guidelines are published, and disease awareness is low, both among clinicians and amongst pathologists, who tend to overlook mild or moderate increases in the density of eosinophils in GI biopsy specimens. Yet, evaluating and, at times, counting eosinophils in GI biopsies may have important clinical implications: the numbers of tissue eosinophils correlate with clinical manifestations, can be used as determinants of effective management, and are used to assess the effects of treatment. A most persuasive argument for providing a count rather than a value judgment is that patients read reports, understand numbers, and use them to help to understand the course of their disease. The objective of this primer is to provide pathologists with the tools to incorporate a quantitative assessment of eosinophilia in the diagnosis of gastric and duodenal biopsy specimens and to develop a systematic approach to their evaluation, counting, and reporting. To achieve this aim, we present our general approach to the biopsy (where to count), followed by details on the characteristics of a countable eosinophil (what to count), and provide with a set of suggestions on the counting methods (how to count). We conclude with suggestions on how to report GI tissue eosinophilia in a manner that alerts clinicians and prompts pertinent management steps.

Helicobacter pylori‐negative Chronic Gastritis in Children

“…According to the criteria proposed by Talley et al, the diagnosis of EoG should be based on both clinical symptoms and histological evidence of significant gastric eosinophilia (>30 eosinophils/5 high power fields, hpf) in the gastric antrum and/or body, whereas endoscopic findings are not essential (16). Although the number of 30 eosinophils/hpf as the upper limit of normal for stomach and duodenum has been proposed, others have suggested lower or higher thresholds (18). Given the patchy nature of EoG, multiple random biopsies are warranted per site (at least 5-6 biopsies) (19).…”

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

“…This pathologist reported a count of 30 or more eosinophils per high‐power field in several gastric biopsies, but then concluded that ‘the number is not sufficient to warrant a diagnosis of eosinophilic gastritis’, even though some would recommend this level for diagnosis. However, in the absence of consensus guidelines, it remains a matter of different opinions 35,36 . One question emerging from these analyses is whether insufficient biopsy sampling could be partially responsible for the low numbers of histopathologic diagnoses of non‐oesophageal EGIDs.…”

“…However, in the absence of consensus guidelines, it remains a matter of different opinions. 35,36 One question emerging from these analyses is whether insufficient biopsy sampling could be partially responsible for the low numbers of histopathologic diagnoses of non-oesophageal EGIDs. Since eosinophilia in the gastrointestinal tract is patchy, could the lack of adequate sampling have hindered the detection of EGIDs?…”

Editorial: the CTA on EGIDs

“…4 Diagnosis of EGIDs is further challenged due to lack of guidelines for histopathologic criteria. 5,6 Another reason for misdiagnosis could be inadequate communication by the endoscopist to the pathologist on suspicion of EGID.…”

“…In one study, there was a mean of 3.6 years from symptoms to diagnosis, and missed diagnosis on index endoscopy in 38.2% of patients 4 . Diagnosis of EGIDs is further challenged due to lack of guidelines for histopathologic criteria 5,6 …”