Evolving Management of Eosinophilic Esophagitis: From Diagnosis to Early Intervention - Episode 5
Recommended Biopsies in EoE and Assessing Severity
Panelists discuss how proper eosinophilic esophagitis (EoE) diagnosis requires at least 6 biopsies from 2 esophageal levels due to the patchy nature of the disease, and how severity assessment using tools such as the AGA IC score incorporates symptoms, endoscopic findings, and histologic features to guide treatment decisions and potentially prevent progression to fibrosis and structuring through earlier intervention.
Current guidelines from the American College of Gastroenterology recommend obtaining at least 6 biopsies from 2 different levels of the esophagus due to EoE’s patchy distribution pattern. Research data demonstrate that diagnostic yield approaches 100% by the 5th or 6th biopsy specimen, emphasizing the importance of adequate sampling. Clinical practice typically involves using 2 separate specimen jars, with one targeting the proximal-mid esophagus and the other focusing on the distal esophagus. Many practitioners take 5 to 6 biopsy samples per jar, totaling 10 to 12 biopsies per procedure to maximize diagnostic accuracy for each esophageal region.
Targeted biopsies should focus on areas showing inflammatory features such as edema, exudates, and furrows, as these locations yield higher eosinophil concentrations. However, biopsies should be obtained even when the esophageal mucosa appears endoscopically normal, as microscopic changes may not be visible during endoscopy. This comprehensive approach ensures that EoE is not missed and helps rule out other conditions when eosinophilia is absent, preventing diagnostic delays and allowing for appropriate alternative diagnoses.
Severity assessment in EoE has historically been challenging due to the complex interplay between symptoms, endoscopic findings, and histological features. The American Gastroenterological Association recently developed an Index of Severity score that incorporates patient age, symptom frequency and severity, endoscopic mucosal findings, and histological characteristics to categorize patients into mild, moderate, or severe disease classifications. This standardized scoring system has demonstrated utility in both pediatric and adult populations and shows reliability for monitoring therapeutic responses. Severe disease typically presents in younger patients with complications such as strictures or food impactions, potentially warranting earlier, more aggressive treatment approaches. The goal of early intervention is preventing disease progression from inflammation to irreversible scarring and fibrosis, similar to severity-based treatment stratification used successfully in asthma management by allergy specialists.
