Yield of Esophageal Biopsy Patterns for the Diagnosis of Eosinophilic Esophagitis.

Background And Aims: The pattern of inflammation in eosinophilic esophagitis (EoE) is patchy, necessitating multiple biopsies to optimize diagnostic yield. Current consensus-based guidelines recommend 6 total biopsies at two sites: distal and either middle or proximal esophagus, although based on limited data. We aimed to determine whether this biopsy protocol sufficiently captures EoE diagnoses by evaluating the distribution of eosinophilia in a large EoE cohort.

Methods: This was a retrospective study of consecutive, newly-diagnosed EoE patients with ≥2 esophageal segments biopsied. Demographics, clinical characteristics/history, endoscopic findings, and histologic results were manually reviewed. Distribution (proximal, middle, and/or distal) of eosinophilia (>15 eosinophils/hpf) was assessed. Predictors for non-distal disease (<15 eosinophils/hpf on distal biopsies) were evaluated using multivariable logistic regression.

Results: 511 newly-diagnosed EoE patients with ≥2 segments biopsied were included. All patients had distal esophageal biopsy. Overall, 286 (56.0%) had ≥1 site with <15 eosinophils/hpf, including 51 (10%) non-distal disease. Among patients with three segments biopsied (n=60), 19 (31.7%) had eosinophilia at only one site, including 6 (10%) isolated mid esophageal disease and no isolated proximal eosinophilia. Discordant mid and proximal biopsy results were found in 18 (30%) patients, with 17/18 (94.4%) mid esophageal eosinophilia. On multivariable analysis, increasing age (OR:1.02, CI:1.002-1.04, p=0.03) and male gender (OR:1.89, CI:1.002-3.55, p=0.049) independently predict non-distal disease.

Conclusions: Isolated segmental eosinophilia is common in EoE, including up to 10% non-distal disease. Discordant mid and proximal biopsy findings are prevalent, with no isolated proximal eosinophilia. Standard protocol should include routine biopsies of both distal and middle esophagus to maximize diagnostic yield.