A Clinical Prediction Tool Identifies Cases of Eosinophilic Esophagitis Without Endoscopic Biopsy: A Prospective Study

Eosinophilic esophagitis (EoE) is difficult to distinguish from gastroesophageal reflux (GERD) and other causes of dysphagia. We assessed the utility of a set of clinical and endoscopic features for predicting EoE without obtaining esophageal biopsies

Accuracy of the Eosinophilic Esophagitis Endoscopic Reference Score in Diagnosis and Determining Response to Treatment

BACKGROUND & AIMS: Little is known about the diagnostic utility of the eosinophilic esophagitis (EoE) endoscopic reference score (EREFS), and how scores change in response to treatment. We investigated the operating characteristics of the EREFS in diagnosis of EoE, how the score changes with treatment, and ways to optimize scoring system. METHODS: We performed a prospective study of adults undergoing outpatient upper endoscopy from August 2011 through December 2013 at the North Carolina School of Medicine. Incident cases of EoE were diagnosed per consensus guidelines and were treated with topical steroids or dietary elimination (n=67); 144 subjects without EoE were included as controls. EREFS scores were compared between cases and controls. For EoE cases, scores were compared before and after treatment. Area under the receiver operator characteristic curve (AUC) analysis was used to determine diagnostic utility of the EREFS system. An iterative analysis was performed to determine optimal EREFS scoring weights. RESULTS: The mean total EREFS score was 3.88 for EoE cases and 0.42 for controls (P>.001); the score identified subjects with EoE with an AUC of 0.934. After treatment of EoE cases, the mean score decreased from 3.88 to 2.01 (P>.001). This change was more prominent for patients with a histologic response (reduction to <15 eos/hpf), compared with non-responders; post-treatment scores were 0.45 for responders vs 3.24 for non-responders (P<.001). A weighted scoring system that doubled exudates, rings, and edema scores maximized the responsiveness of the total EREFS score. CONCLUSIONS: The EREFS classification system identifies patients with EoE an AUC of 0.934; the score decreases with treatment, and histologic responders have significantly lower scores than non-responders. This system can therefore be used to identify individuals with EoE and used as an endoscopic outcome measure to follow their response to treatment

The esophageal biopsy “pull” sign: a highly specific and treatment-responsive endoscopic finding in eosinophilic esophagitis (with video)

BACKGROUND AND AIMS: Esophageal biopsies in patients with eosinophilic esophagitis (EoE) can feel firm, with resistance appreciated when pulling the forceps to obtain the tissue sample. We aimed to assess the diagnostic utility of the esophageal biopsy pull sign, and determine its histologic associations and response to treatment. METHODS: This was a prospective cohort study of adults undergoing outpatient upper endoscopy. Cases of EoE were diagnosed per consensus guidelines and were subsequently treated with either topical steroids or dietary elimination. Controls were subjects who did not have EoE. The frequency of the esophageal biopsy pull sign was assessed in EoE cases and controls, and diagnostic metrics were calculated. The pull sign was also reassessed in cases after therapy. RESULTS: 83 EoE cases and 121 controls were included. 63 EoE cases (76%) were pull sign positive compared with just 2 controls (2%; p < 0.001), corresponding to a sensitivity and specificity of 76% and 98%, positive and negative predictive values of 97% and 86%, and positive and negative likelihood ratios of 45.9 and 0.245. The pull sign was the strongest endoscopic predictor of EoE case status at baseline, and was less frequent after successful treatment (20% vs 79%; p < 0.001). CONCLUSIONS: The “pull” sign is highly specific for EoE, and is rarely seen in non-EoE controls. In patients with EoE who respond to treatment, the pull sign often resolves. The pull sign may be a simple and easily obtained measure of esophageal remodeling

Utility of a Noninvasive Serum Biomarker Panel for Diagnosis and Monitoring of Eosinophilic Esophagitis: A Prospective Study

OBJECTIVES: Non-invasive biomarkers would be valuable for diagnosis and monitoring of eosinophilic esophagitis (EoE). The aim of this study was to determine the utility of a panel of serum biomarkers for the diagnosis and management of EoE. METHODS: We conducted a prospective cohort study of consecutive adults undergoing outpatient EGD. Incident cases of EoE were diagnosed per consensus guidelines; controls had GERD or dysphagia and did not meet EoE criteria. EoE cases were treated with topical steroids and had repeat endoscopy. Pre- and post-treatment serum samples were analyzed in a blinded fashion for: IL-4, IL-5, IL-6, IL-9, IL-13, TGF-α, TGF-β, TNF-α, eotaxin-1, -2, and -3, TSLP, major basic protein (MBP), and eosinophil-derived neurotoxin (EDN). Cases and controls were compared at baseline, and pre- and post-treatment assays were compared in cases. RESULTS: A total of 61 incident EoE cases and 87 controls were enrolled; 51 EoE cases had post-treatment serum analyzed. There were no significant differences in any of the biomarkers between EoE cases and controls at baseline. IL-13 and eotaxin-3 for cases and controls were 85 ±160 vs 43 ±161 pg/mL (p=0.12), and 41 ±159 vs 21 ±73 (p=0.30). There were no significant differences in assay values among cases before and after treatment. There were also no differences after stratification by atopic status or treatment response. CONCLUSIONS: A panel of inflammatory factors known to be associated with EoE pathogenesis were not increased in the serum, nor were they responsive to therapy. None of these biomarkers are likely candidates for a serum test for EoE. Histologic analysis for diagnosis and management of EoE continues to be necessary, and novel, less invasive, biomarkers are needed

A Clinical Prediction Tool Identifies Cases of Eosinophilic Esophagitis Without Endoscopic Biopsy: A Prospective Study

OBJECTIVES: Eosinophilic esophagitis (EoE) is difficult to distinguish from gastroesophageal reflux (GERD) and other causes of dysphagia. We assessed the utility of a set of clinical and endoscopic features for predicting EoE without obtaining esophageal biopsies. METHODS: We prospectively enrolled consecutive adults undergoing outpatient upper endoscopy at University of North Carolina from 7/2011–12/2013. Incident cases of EoE were diagnosed per consensus guidelines. Non-EoE controls had either GERD- or dysphagia-predominant symptoms. A predictive model containing clinical and endoscopic, but no histologic data was assessed. Receiver operator characteristic (ROC) curves were constructed and the area under the curve (AUC) was calculated. RESULTS: A total of 81 EoE cases (mean age 38 years; 60% male; 93% white; 141 eos/hpf) and 144 controls (mean age 52, 38% male; 82% white; 3 eos/hpf) were enrolled. A combination of clinical (age, sex, dysphagia, food allergy) and endoscopic (rings, furrows, plaques, hiatal hernia) features was highly predictive of EoE. The AUC was 0.944, with sensitivity, specificity, and accuracy of 84%, 97%, and 92%. Similar values were seen after limiting controls to those with only reflux or dysphagia, or to those with esophageal eosinophilia not due to EoE. CONCLUSIONS: We validated a set of clinical and endoscopic features to predict EoE with a high degree of accuracy, and allow identification of those at very low risk of disease. Use of these predictors at the point-of-care will avoid the effort and expense of low-yield histological examinations for EoE

Association Between Body Mass Index and Clinical and Endoscopic Features of Eosinophilic Esophagitis

BACKGROUND: Because eosinophilic esophagitis (EoE) causes dysphagia, esophageal narrowing, and strictures, it could result in low body mass index (BMI), but there are few data assessing this. AIM: To determine whether EoE is associated with decreased BMI. METHODS: We conducted a prospective study at the University of North Carolina from 2009–2013 enrolling consecutive adults undergoing outpatient EGD. BMI and endoscopic findings were recorded. Incident cases of EoE were diagnosed per consensus guidelines. Controls had either reflux or dysphagia, but not EoE. BMI was compared between cases and controls and by endoscopic features. RESULTS: Of 120 EoE cases and 297 controls analyzed, the median BMI was lower in EoE cases (25 kg/m(2) vs. 28 kg/m(2), p=0.002). BMI did not differ by stricture presence (26 kg/m(2) vs. 26 kg/m(2), p=0.05) or by performance of dilation (26 kg/m(2) vs. 27 for undilated; p=0.16). However, BMI was lower in patients with narrow caliber esophagus (24 kg/m(2) vs. 27, p<0.001). EoE patients with narrow caliber esophagus also had decreased BMI compared to controls with narrow caliber esophagi (24 kg/m(2) vs. 27, p=0.001). On linear regression after adjustment for age, race, and gender, narrowing decreased BMI by 2.3 kg/m(2) [95% CI −4.1, −0.6]. CONCLUSIONS: BMI is lower in EoE cases compared to controls, and esophageal narrowing, but not focal stricture, is associated with a lower BMI in patients with EoE. Weight loss or low BMI in a patient suspected of having EoE should raise concern for esophageal remodeling causing narrow caliber esophagus