Elsevier

Gastrointestinal Endoscopy

Volume 64, Issue 3, September 2006, Pages 313-319
Gastrointestinal Endoscopy

Original Article
Histopathologic variability and endoscopic correlates in adults with eosinophilic esophagitis

https://doi.org/10.1016/j.gie.2006.04.037Get rights and content

Background

Recently recognized as an important cause of dysphagia and food impaction in adults, eosinophilic esophagitis (EE) is diagnosed by histologic findings of increased mucosal eosinophils.

Objective

We examined variability in histopathologic features of adults with EE to derive a recommendation on the optimal number and location of biopsies needed for diagnosis.

Design

Charts were reviewed from 74 patients diagnosed with EE based on ≥15 eosinophils per high-power field (eos/hpf). Biopsy specimens were prospectively analyzed for the degree of eosinophilia and histopathologic features of EE. Subgroup analysis was performed in patients with biopsy specimens from both the proximal and the distal esophagus. The biopsy specimens from patients with EE were compared with specimens from biopsied Schatzki's ring.

Setting

Northwestern University Feinberg School of Medicine.

Patients

Charts were reviewed for 74 adult patients and biopsy specimens were available for 66 patients.

Results

A total of 341 biopsy specimens from 66 patients were available for analysis and revealed marked variability within and between biopsy specimens of individual patients. The median eos/hpf was 107 (0-557 eos/hpf). By using criteria of ≥15 eos/hpf for diagnosis, we found that 1 biopsy specimen had a sensitivity of 55%, which increased to 100% after 5 biopsies. By using stricter criteria, additional biopsy specimens were needed to achieve 100% sensitivity. Despite a higher eosinophilia in distal (82 eos/hpf) compared with proximal biopsy specimens (68 eos/hpf), this difference was not statistically significant. There was marked difference between eosinophilia in mucosal biopsy specimens of patients with EE (82 eos/hpf) compared with Schatzki's ring (0.3 eos/hpf).

Conclusions

Significant histologic variability exists among biopsy specimens from individual patients with EE and necessitates multiple biopsies to improve diagnostic sensitivity. No significant difference in eosinophilia was demonstrated between proximal and distal sites.

Section snippets

Patients and methods

We reviewed the charts of 74 adult patients with a known diagnosis of EE, based on an eosinophil count exceeding 15 eos/hpf, seen at our hospital from January 1999 to July 2004. Patients with concomitant eosinophilic infiltration in the stomach or the duodenum were excluded. Data, including sex, age, nature and duration of symptoms, medical history, allergies, medications, peripheral eosinophilia, and family history, were recorded. Endoscopic findings were also recorded. Results from a barium

Demographics

During the study period, 89 patients were encountered with a suspected diagnosis of EE based on endoscopic findings. Of these, 74 had a diagnosis of EE confirmed by histology and were included. Despite characteristic endoscopic features of EE, 15 patients were excluded because their biopsy specimens did not demonstrate significant eosinophilia. The median number of biopsy specimens taken in the excluded group was 4 (range, 2-8). Every hpf of each biopsy specimen was reviewed to assure that the

Discussion

Our study included 74 adult patients with EE, making it the largest adult series and the first prospective histopathologic analysis reported. Because the diagnosis of EE is based on histopathology, we examined the optimal number and location of biopsy specimens necessary for diagnosis. Significant variability exists in eosinophil concentrations among biopsy specimens, such that limited biopsy sampling may lead to false-negative results. Based on our data, by using a diagnostic threshold of ≥15

Acknowledgments

The authors wish to thank Peter J. Kahrilas, MD, for his critical review of this manuscript and support of this study. The authors would also like to thank the Gastroenterology faculty and fellows at Northwestern University for their recruitment of patients.

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