EA Pasman et al. Clin Gastroenterol Hepatol 2023; 21: 1108-1110. Quantitative Analysis of Tug Sign: An Endoscopic Finding of Eosinophilic Esophagitis

Background: “Chronic inflammation can lead to tissue remodeling in the esophagus with fibrosis in the lamina propria that is partially responsible for symptoms and complications of EoE.^3,4 At times, a firmness to the esophagus can be appreciated with a noticeable force required to obtain biopsies from EoE. This sensation has been described as the “tug” or “pull” sign.^5,6“

Methods: in this prospective study with 159 patients (128 pediatric, 31 adult), the authors devised a digital force gauge to measure the force required to take biopsy specimens. The study included 88 patients with EoE and 71 controls.

Key finding:

• EoE patients showed an increase in the mean force required to obtain biopsies: 14.9 Newton (N) compared to 11.6 in control group
• Peak force was greater in EoE patients: 20.4 N compared to 15 N in control group.
• The pediatric subgroup had higher peak force in EoE patients: 22.4 N compered to 16.1 N for control group

My take: I had not heard of the term “Tug” sign for EoE, though it is something that is intuitive for GI providers who care for these patients. This study quantifies this problem.

“When you can measure what you are speaking about and express it in numbers, you know something about it; but when you cannot express it in numbers, your knowledge is of a meagre and unsatisfactory kind” –Lord Kelvin 1883

Related topic: Recent bowel sounds episode with Amanda Muir discussed eosinophilic esophagitis. A few pointers:

• Useful YouTube video explaining how to swallow inhaled steroid (from Glen Furuta/Colorado Chilren’s): How to Use an Inhaler for EoE
• Budesonide can be administered with 1 tsp honey, 1 tsp maple syrup or with 1 tsp apple sauce
• Approximate equivalent dose of Flovent 4 puffs of 220 mcg =~1 mg budesonide
• Elemental feedings are difficult to maintain and used much less, mainly in children who already have enteral tubes.