JB Wechsler et al. Clin Gastroenterol Hepatol 2022; 20: 1971-1976. Defining the Patchy Landscape of Esophageal Eosinophilia in Children With Eosinophilic Esophagitis

Design: The authors prospectively obtained 3-site esophageal biopsies based on rigorous endoscopic measurements of the proximal, mid, and distal esophagus and gastroesophageal junction. Biopsies were reviewed by a pathologist, and those with at least 15 eosinophils per high-power field were considered active EoE.  

Key findings:

• 304 endoscopies in 167 patients had active EoE. The entire cohort was 217 patients (n=596 endoscopies)
• Among the 304 endoscopies with active EoE, 9 had focal eosinophilia restricted to the mid esophagus, and 8 were restricted to the proximal esophagus
• Distal + proximal biopsies had the highest diagnostic sensitivity for a 2-site combination (~98% sensitivity)

Based on this study, the authors recommend “3-site biopsies for optimal disease assessment of active EoE in children.”

My take: I think recommendations to add more and more biopsies is premature until we have evidence that identifying “focal” inflammation in the mid-esophagus has some clinical usefulness/improves outcomes. To me, a 2% increase in sensitivity over 2-site biopsies is negligible & in all likelihood, a 4-site biopsy protocol would increase the yield even further.

Related blog posts:

• I-SEE for Eosinophilic Esophagitis
• 4-14-4 Rule: More Biopsies Needed For Eosinophilic Esophagitis
• Best Approach for Identifying Eosinophilic Esophagitis 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. Also, 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.
• Looking Twice for Eosinophilic Esophagitis
• Updated Consensus Guidelines for Eosinophilic Esophagitis