Can a patient with dysphagia and intact gag reflex, on Proton Pump Inhibitor (PPI) without improvement, with Esophagogastroduodenoscopy (EGD) findings of loss of vascular markings, glycogen vesicles, concentric rings, linear furrows, and grade A reflux esophagitis, still have eosinophilic esophagitis (EoE) despite biopsies showing no increased eosinophils?

From the Guidelines

Yes, this patient could potentially have eosinophilic esophagitis (EoE) despite the biopsies not showing increased eosinophils. The endoscopic findings of concentric rings, linear furrows, and loss of vascular markings are highly suggestive of EoE, even though the biopsies did not show increased eosinophils. This discrepancy could occur for several reasons:

• Patchy distribution of eosinophils in EoE, which may have been missed in the biopsies taken, as noted in the British Society of Gastroenterology guidelines 1.
• The patient's use of a proton pump inhibitor (PPI) may have temporarily reduced eosinophil counts, as suggested by the British Society of Gastroenterology guidelines 1, which recommend withdrawing PPIs for at least three weeks prior to endoscopy and biopsy.
• Some cases of EoE can have endoscopic findings without significant eosinophilia on initial biopsies. To further evaluate for EoE, consider the following steps:
• Repeat endoscopy with multiple biopsies (at least 6) from different levels of the esophagus after discontinuing PPI for 4-8 weeks, as recommended by the British Society of Gastroenterology guidelines 1.
• If repeat biopsies are negative but clinical suspicion remains high, consider a trial of topical steroid therapy (e.g., fluticasone 440 mcg twice daily or budesonide 1 mg twice daily for 8 weeks) to see if symptoms improve.
• Perform allergy testing to identify potential food triggers. Understanding the possibility of EoE despite initial negative biopsies is crucial for proper management, as untreated EoE can lead to esophageal remodeling and strictures over time, highlighting the importance of considering the clinical, endoscopic, and histological features of EoE, as emphasized in the British Society of Gastroenterology guidelines 1.

From the Research

Eosinophilic Esophagitis Diagnosis and Characteristics

• Eosinophilic esophagitis (EoE) is a chronic immune-mediated disease of the esophagus, characterized by an eosinophil-rich, Th2 antigen-mediated response 2.
• The diagnosis of EoE is based on a combination of clinical, endoscopic, and histological findings, with a definitive diagnosis requiring an eosinophil count of at least 15 eosinophils per high power field (HPF) in esophageal biopsies 3, 4.
• Endoscopic findings in EoE may include loss of vascular markings, glycogen vesicles, concentric rings, linear furrows, and esophagitis, which are assessed using the EREFS system 3.

Proton Pump Inhibitor (PPI) Treatment and EoE

• PPIs are commonly used in the treatment of EoE, particularly in patients with concomitant gastroesophageal reflux disease (GERD) symptoms 2, 5.
• However, the presence of EoE cannot be ruled out solely based on a lack of response to PPI treatment, as some patients with EoE may not respond to PPIs 5.

Biopsy Findings and EoE Diagnosis

• The absence of increased eosinophils in biopsies does not necessarily rule out EoE, as the disease can be patchy and biopsies may not always capture the affected areas 3, 4.
• Other histological features, such as those included in the EoE histologic scoring system (EoEHSS), can be supportive of the diagnosis and assessment of inflammatory activity 3.

Clinical Considerations

• Patients with dysphagia and intact gag reflex, on PPI without improvement, and with EGD findings suggestive of EoE, may still have EoE despite biopsies showing no increased eosinophils 6, 5.
• Clinicians should consider obtaining esophageal biopsies in patients with cardinal EoE symptoms, particularly those with supportive endoscopic evidence and younger than 65 years old 6.