A Godat et al. Clin Gastroenterol Hepatol 2024: 22: 1528-1530. Eosinophil Distribution in Eosinophilic Esophagitis and its Impact on Disease Activity and Response to Treatment

In this post hoc analysis of the EOS-1 and EOS-2 trials with 263 adult patients, the authors analyzed eosinophil distribution and impact on treatment. Key findings;

• Peak eosinophil count was highest in the distal esophagus (median 166 eos/mm2) followed by mid esophagus (142) and then proximal esophagus (113). 46% of patients had highest peak eosinophil count in the distal esophagus, 33% in the mid esophagus, and 21% of patients in the proximal esophagus
• Diagnosis: a biopsy protocol using only distal esophagus would have missed EoE diagnosis in only 13 (4.9%) of patients
• Remission rates stratified by histologic categories were not statistically different base on disease location: 73% distal esophagus, 76% mid esophagus, 64% proximal esophagus, and 64% diffuse esophageal disease
• None of the following factors affected treatment outcome: histologic location category, histologic disease severity (peak eos count) and atopic status. For example, treatment failure occurred in 37% without atopy and 30% with atopy

My take: In this study population, separate evaluation of biopsies by location modestly increased the diagnostic yield at baseline. Thus, additional biopsies at disease onset is a good idea. However, the actual distribution of disease activity did not seem to help provide any insight into therapeutic response (to budesonide). Practical implications are that fewer biopsies on follow-up endoscopy may be reasonable to help determine a treatment response.

Related blog posts.

• How Useful Are 3-site Esophageal Biopsies for Eosinophilic Esophagitis
• Practical Tips for Eosinophilic Esophagitis lecture from Dr. Glenn Furuta
• 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
• Practical Guide to Dietary Therapy for Eosinophilic Esophagitis This link to an open access article provides extensive useful advice of dietary therapy for EoE
• “Tug” Sign For Eosinophilic Esophagitis and EoE Bowel Sounds Tips
• What is EoE?
• Long-Term Treatment of Eosinophilic Esophagitis with Budesonide
• Dupilumab: FDA Approval for Eosinophilic Esophagitis
• 2020 Eosinophilic Guidelines (AGA)