Eosinophilic Esophagitis
Eosinophilic Esophagitis
When EoE is suspected clinically based on the above symptoms, esophagogastroduodenoscopy is required to evaluate the esophagus, assess for other potential causes, and obtain esophageal biopsies. There are multiple characteristic endoscopic findings in EoE, but these endoscopic findings are also not specific for diagnosis of EoE and interobserver and intraobserver endoscopic agreement for these findings is only fair. Esophageal rings can either be fixed (this finding has previously been termed esophageal trachealization or corrugation; Fig. 1a) or transient (previously termed felinization; Fig. 1b). Linear or longitudinal furrows are mucosal grooves that run parallel to the long axis of the esophagus (Fig. 1c) and white plaques or exudates can coat the esophagus (Fig. 1d) and may mimic the appearance of candida. In some cases the mucosa appears pale, congested, or has decreased vascularity (Fig. 1c and d). Because the mucosa is fragile it can fracture with passage of the endoscope if the esophagus is narrow in caliber, a phenomenon termed creêpe-paper mucosa (Fig. 1e).
(Enlarge Image)
Figure 1.
Typical endoscopic findings in eosinophilic esophagitis. (a) Fixed esophageal rings, previously termed corrugation or trachealization. (b) Transient esophageal rings, previously termed felinization. (c) Linear furrows, as well as mucosal pallor, congestion, and loss of vascularity. (d) White plaques and exudates, as well as mucosal pallor, congestion, and loss of vascularity. (e) Crêpe-paper mucosa with a mucosal rent after passage of the endoscope through a narrow caliber esophagus. This occurred without endoscopic dilation.
Esophageal biopsies are currently required to diagnose EoE. Because 10–20% of EoE patients can have an endoscopically normal appearing esophagus, it is recommended that esophageal biopsies should be obtained in all patients suspected of having EoE, including all patients who undergo upper endoscopic evaluation for unexplained dysphagia, regardless of the endoscopic appearance or findings.
The approach to obtaining esophageal biopsies is informed by studies showing that esophageal eosinophilic infiltrate in EoE is patchy and can vary between the proximal and distal esophagus. Because a single esophageal biopsy samples only a tiny fraction of the mucosal surface, increasing the number of biopsies and including tissue from different esophageal locations improves the sensitivity of diagnosis. Two studies, one in adults and one in children, suggest that sensitivity is maximized when at least five biopsies are obtained. Therefore, the current recommendation is to take at least two to four biopsies from the distal and two to four biopsies from the proximal esophagus.
Endoscopic Findings in Eosinophilic Esophagitis
When EoE is suspected clinically based on the above symptoms, esophagogastroduodenoscopy is required to evaluate the esophagus, assess for other potential causes, and obtain esophageal biopsies. There are multiple characteristic endoscopic findings in EoE, but these endoscopic findings are also not specific for diagnosis of EoE and interobserver and intraobserver endoscopic agreement for these findings is only fair. Esophageal rings can either be fixed (this finding has previously been termed esophageal trachealization or corrugation; Fig. 1a) or transient (previously termed felinization; Fig. 1b). Linear or longitudinal furrows are mucosal grooves that run parallel to the long axis of the esophagus (Fig. 1c) and white plaques or exudates can coat the esophagus (Fig. 1d) and may mimic the appearance of candida. In some cases the mucosa appears pale, congested, or has decreased vascularity (Fig. 1c and d). Because the mucosa is fragile it can fracture with passage of the endoscope if the esophagus is narrow in caliber, a phenomenon termed creêpe-paper mucosa (Fig. 1e).
(Enlarge Image)
Figure 1.
Typical endoscopic findings in eosinophilic esophagitis. (a) Fixed esophageal rings, previously termed corrugation or trachealization. (b) Transient esophageal rings, previously termed felinization. (c) Linear furrows, as well as mucosal pallor, congestion, and loss of vascularity. (d) White plaques and exudates, as well as mucosal pallor, congestion, and loss of vascularity. (e) Crêpe-paper mucosa with a mucosal rent after passage of the endoscope through a narrow caliber esophagus. This occurred without endoscopic dilation.
Esophageal biopsies are currently required to diagnose EoE. Because 10–20% of EoE patients can have an endoscopically normal appearing esophagus, it is recommended that esophageal biopsies should be obtained in all patients suspected of having EoE, including all patients who undergo upper endoscopic evaluation for unexplained dysphagia, regardless of the endoscopic appearance or findings.
The approach to obtaining esophageal biopsies is informed by studies showing that esophageal eosinophilic infiltrate in EoE is patchy and can vary between the proximal and distal esophagus. Because a single esophageal biopsy samples only a tiny fraction of the mucosal surface, increasing the number of biopsies and including tissue from different esophageal locations improves the sensitivity of diagnosis. Two studies, one in adults and one in children, suggest that sensitivity is maximized when at least five biopsies are obtained. Therefore, the current recommendation is to take at least two to four biopsies from the distal and two to four biopsies from the proximal esophagus.
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