Best Approach for Identifying Eosinophilic Esophagitis

A recent study (K Radicic, RF Stokes. Clin Gastroenterol Hepatol 2019; 1408-9) indicated that taking biopsies from three esophageal areas (proximal, mid, and distal)  improved the likelihood of identifying eosinophilic esophagitis (EoE).

Key findings:

  • In their study, among 96 patients with EoE, 55.2% were positive (>15 eos/hpf) in only 1 of the 3 levels.
  • 17 patients (17.7%) were positive in the mid-esophagus alone, and 6 patients (6.3%) were positive in the proximal esophagus alone.

The authors state that a 2-level biopsy protocol missed the diagnosis of EoE in roughly 1 of 5 patients.

My take: This study is provocative. However, the reasons why 3 levels improved their yield could be related to other factors rather than location.

  1. Prior studies have shown higher yield when taking 5 or 6 biopsies rather than fewer biopsies; thus, the location of biopsies may not be as important as the number of specimens
  2. Prior studies have shown that having another pathologist review the slides can increase the yield by ~20%; this indicates that careful review of specimens by itself is helpful.  Perhaps, more specimen containers will increase the time that a pathologist reviews the biopsies.

My view is that if adequate numbers of biopsies are taken from several locations, a single jar for all the specimens should suffice (& reduce costs) –though a formal study could be beneficial to confirm this.

Related blog posts:

From NASPGHAN 2014 EoE Slide Set

9 thoughts on “Best Approach for Identifying Eosinophilic Esophagitis

  1. Hi Dr. Hochman,
    I always enjoy reading your blog posts. While I am admittedly not a physician, I do have a bit of a challenge question with this one. To your point that putting all specimens in one jar could reduce costs and would capture the information of eosinophil counts leaves me with the obvious question that there is no way to tell where the biopsies were pulled from. How would the pathologist differentiate the upper and lower specimens?

    The inability to understand the location of eosinophil-infiltrate (coupled with the other clinical and endoscopic findings) could potentially muddy whether you have a GERD or EoE patient on your hands. I think avoiding a potential re-scope vs. a few dollars is the stronger argument for total patient care.

    Your thoughts?
    Beth Allen

    • Thanks for your comments. In pediatrics, having multiple jars rarely helps distinguish GERD from EoE. The key feature is how many eosinophils are present in a high power field (hpf) and looking at a sufficient number of specimens as the condition can be patchy. With EoE, one of the key features is having more than 15 eos per hpf; generally with reflux there are much fewer numbers of eosinophils.


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