Original article—alimentary tract
Clinical, Endoscopic, and Histologic Findings Distinguish Eosinophilic Esophagitis From Gastroesophageal Reflux Disease

https://doi.org/10.1016/j.cgh.2009.08.030Get rights and content

Background & Aims

Features of eosinophilic esophagitis (EoE) and gastroesophageal reflux disease (GERD) overlap; because they cannot be differentiated on the basis of eosinophil counts alone, it can be a challenge to distinguish these disorders. We aimed to characterize the clinical, endoscopic, and histologic features of EoE and GERD and to identify factors that might be used to differentiate them.

Methods

We performed a retrospective case-control study on data collected from 2000 to 2007. Cases were patients of any age with EoE, as defined by recent consensus guidelines; controls were patients of any age with GERD. Clinical and endoscopic data were collected, and all esophageal biopsy specimens were reassessed by gastrointestinal pathologists. Cases and controls were compared, unconditional logistic regression was performed to develop a model to predict EoE, and receiver operator characteristic curves were constructed.

Results

Data from 151 patients with EoE and 226 with GERD were analyzed. Compared with GERD, features that independently predicted EoE included younger age; symptoms of dysphagia; documented food allergies; observations of esophageal rings, linear furrows, white plaques, or exudates by upper endoscopy; an absence of a hiatal hernia, observed by upper endoscopy; a higher maximum eosinophil count; and the presence of eosinophil degranulation observed in biopsy specimens. The area under the curve for this model was 0.934.

Conclusions

We identified a set of readily available and routinely measured variables that differentiate EoE from GERD. Use of this type of analysis with patients suspected to have EoE might lead to more accurate diagnoses.

Section snippets

Study Design and Patients

We conducted a retrospective case-control study at the University of North Carolina (UNC) Hospitals. All patients were selected from the UNC EoE clinicopathologic database, which contains information on patients with esophageal eosinophilia from any cause from January 2000 through December 2007. This resource was originally constructed by searching the UNC pathology database for every esophageal biopsy obtained during this time frame and then narrowing the search to those reports with any

Study Subjects

Of the 456 candidate patients identified in the database for this study, 151 were found to have EoE meeting our case definition, and 226 had GERD meeting our control definition. Of the EoE patients, 79 (52%) had persistent eosinophilia on esophageal biopsy while on acid suppression (69 with a proton pump inhibitor [PPI] and an additional 10 with an H2-receptor antagonist); the remainder did not have a symptom response to acid suppression. There were 22 patients who had either EoE or GERD, but

Discussion

Because the clinical features and histologic findings of EoE are nonspecific and can overlap with GERD and because distinguishing these 2 entities is critical for appropriate patient care, we performed a case-control study comparing patients with EoE with those with GERD. The goal was to determine factors that could reliably differentiate the 2 groups of patients. We found that individual clinical factors (such as age and gender, symptoms of dysphagia and food impaction, the presence of atopic

References (40)

  • A. Straumann et al.

    Natural history of primary eosinophilic esophagitis: a follow-up of 30 adult patients for up to 11.5 years

    Gastroenterology

    (2003)
  • C.A. Liacouras et al.

    Eosinophilic esophagitis: a 10-year experience in 381 children

    Clin Gastroenterol Hepatol

    (2005)
  • M. Remedios et al.

    Eosinophilic esophagitis in adults: clinical, endoscopic, histologic findings, and response to treatment with fluticasone propionate

    Gastrointest Endosc

    (2006)
  • N. Gonsalves et al.

    Histopathologic variability and endoscopic correlates in adults with eosinophilic esophagitis

    Gastrointest Endosc

    (2006)
  • A.H. Assa'ad et al.

    Pediatric patients with eosinophilic esophagitis: an 8-year follow-up

    J Allergy Clin Immunol

    (2007)
  • M.H. Collins et al.

    Clinical, pathologic, and molecular characterization of familial eosinophilic esophagitis compared with sporadic cases

    Clin Gastroenterol Hepatol

    (2008)
  • R.C. Kapel et al.

    Eosinophilic esophagitis: a prevalent disease in the United States that affects all age groups

    Gastroenterology

    (2008)
  • H.S. Winter et al.

    Intraepithelial eosinophils: a new diagnostic criterion for reflux esophagitis

    Gastroenterology

    (1982)
  • S.N. Sgouros et al.

    Eosinophilic esophagitis in adults: a systematic review

    Eur J Gastroenterol Hepatol

    (2006)
  • E.S. Dellon et al.

    Variability in diagnostic criteria for eosinophilic esophagitis: a systematic review

    Am J Gastroenterol

    (2007)
  • Cited by (282)

    • Endoscopic Features of Eosinophilic Esophagitis

      2024, Immunology and Allergy Clinics of North America
    • Clinical Evaluation of the Adult with Eosinophilic Esophagitis

      2024, Immunology and Allergy Clinics of North America
    View all citing articles on Scopus

    This article has an accompanying continuing medical education activity on page 1261. Learning Objectives—At the end of this activity, the learner should be able to differentiate eosinophilic esophagitis from gastroesophageal reflux disease based on clinical, endoscopic, and histological clues.

    View this article's video abstract at www.cghjournal.org.

    Conflicts of interest The authors disclose no conflicts.

    Funding This work is funded in part by a Junior Faculty Development Award from the American College of Gastroenterology and NIH award number KL2RR025746 from the National Center for Research Resources.

    View full text