Background & Aims Little is known about the diagnostic utility of the eosinophilic esophagitis (EoE) endoscopic reference score (EREFS), and how scores change in response to treatment. We investigated the operating characteristics of the EREFS in diagnosis of EoE, how the score changes with treatment, and ways to optimize scoring system. Methods We performed a prospective study of adults undergoing outpatient upper endoscopy from August 2011 through December 2013 at the North Carolina School of Medicine. Incident cases of EoE were diagnosed per consensus guidelines and were treated with topical steroids or dietary elimination (n=67); 144 subjects without EoE were included as controls. EREFS scores were compared between cases and controls. For EoE cases, scores were compared before and after treatment. Area under the receiver operator characteristic curve (AUC) analysis was used to determine diagnostic utility of the EREFS system. An iterative analysis was performed to determine optimal EREFS scoring weights. Results The mean total EREFS score was 3.88 for EoE cases and 0.42 for controls (P>.001); the score identified subjects with EoE with an AUC of 0.934. After treatment of EoE cases, the mean score decreased from 3.88 to 2.01 (P>.001). This change was more prominent for patients with a histologic response (reduction to <15 eos/hpf), compared with non-responders; post-treatment scores were 0.45 for responders vs 3.24 for non-responders (P<.001). A weighted scoring system that doubled exudates, rings, and edema scores maximized the responsiveness of the total EREFS score. Conclusions The EREFS classification system identifies patients with EoE an AUC of 0.934; the score decreases with treatment, and histologic responders have significantly lower scores than non-responders. This system can therefore be used to identify individuals with EoE and used as an endoscopic outcome measure to follow their response to treatment.

Objectives:Management of eosinophilic esophagitis (EoE) requires repeated endoscopic mucosal sampling to assess disease activity. A less invasive and expensive means of monitoring of EoE is required. The objective of this study was to assess the accuracy, safety, and tolerability of the cytosponge compared to endoscopy and biopsy for histologic assessment of EoE.Methods:In this prospective two-center cross-sectional study, patients with known EoE underwent cytosponge sampling followed by endoscopy and biopsy. Sample adequacy and eosinophil counts (eos/HPF) were determined for both cytosponge and endoscopic samples. The cytosponge was assessed for diagnostic accuracy, safety, and patient preference as compared to endoscopy.Results:Six patients (7%) failed to swallow the sponge. One hundred and five procedures were successfully performed in 80 patients (66% male, 100% white, 19% stricture). The cytosponge sample was adequate in 102 and the biopsy in 104; 101 procedures had adequate samples by both techniques. Fifty-seven biopsies were graded as active EoE with ≥15 eos/HPF as the gold standard. Eosinophil counts highly correlated between the biopsy and cytosponge (r=0.78, P<0.0001). Using a cutoff of ≤15 eos/HPF for inactive disease, the sensitivity and specificity of the cytosponge was 75% and 86%, respectively. Six patients had active EoE on cytosponge not found on biopsy. For biopsies with inactive EoE, the cytosponge identified 38/44. No complications occurred, and cytosponge endoscopic abrasion scores were low (0.34/4). Patients preferred cytosponge to endoscopy with higher rating scores (7.27 vs. 6.11, P=0.002).Conclusions:Compared to endoscopy with biopsy, cytosponge provided a minimally invasive, safe, well tolerated, and accurate method to assess EoE histologic activity. (ClinicalTrial.gov number NCT01585103).

Objectives Eosinophilic esophagitis (EoE) is difficult to distinguish from gastroesophageal reflux (GERD) and other causes of dysphagia. We assessed the utility of a set of clinical and endoscopic features for predicting EoE without obtaining esophageal biopsies. Methods We prospectively enrolled consecutive adults undergoing outpatient upper endoscopy at University of North Carolina from 7/2011–12/2013. Incident cases of EoE were diagnosed per consensus guidelines. Non-EoE controls had either GERD- or dysphagia-predominant symptoms. A predictive model containing clinical and endoscopic, but no histologic data was assessed. Receiver operator characteristic (ROC) curves were constructed and the area under the curve (AUC) was calculated. Results A total of 81 EoE cases (mean age 38 years; 60% male; 93% white; 141 eos/hpf) and 144 controls (mean age 52, 38% male; 82% white; 3 eos/hpf) were enrolled. A combination of clinical (age, sex, dysphagia, food allergy) and endoscopic (rings, furrows, plaques, hiatal hernia) features was highly predictive of EoE. The AUC was 0.944, with sensitivity, specificity, and accuracy of 84%, 97%, and 92%. Similar values were seen after limiting controls to those with only reflux or dysphagia, or to those with esophageal eosinophilia not due to EoE. Conclusions We validated a set of clinical and endoscopic features to predict EoE with a high degree of accuracy, and allow identification of those at very low risk of disease. Use of these predictors at the point-of-care will avoid the effort and expense of low-yield histological examinations for EoE.

Summary Background Periostin is highly expressed in eosinophilic esophagitis (EoE), but has not been extensively studied as a non-invasive biomarker. Aim To assess whether serum periostin distinguished EoE from controls at baseline, had utility for monitoring treatment response, or was associated with IL-13 levels. Methods This was a sub-analysis of a prospective cohort study of adults undergoing outpatient upper endoscopy. Incident cases of EoE were diagnosed per consensus guidelines. Controls were subjects with either GERD or dysphagia without EoE. EoE patients were treated with swallowed/topical steroids and had repeat endoscopy/biopsy. Serum periostin levels for cases and controls were compared at baseline, and pre/post-treatment levels were compared for cases. Serum IL-13 and tissue expression of periostin were also assessed. Results A total of 61 incident EoE cases and 87 controls were analyzed. Despite a marked increase in tissue periostin expression in cases, the median baseline serum periostin level was only slightly higher in cases than controls (22.1 ng/mL vs 20.7; p=0.04); there was no change in post-treatment levels. There was also no difference in serum periostin for cases by histologic response or atopic status. There was a strong trend towards higher serum IL-13 levels in cases in the highest periostin quartile (57.1 pg/mL vs 2.6; p=0.07). Conclusions Serum periostin levels were similar in cases and controls, and there were no changes post-treatment. Given elevated IL-13 levels in the EoE patients with the highest periostin levels, future studies could explore periostin as a biomarker in EoE, perhaps in the setting of anti-IL-13 therapy.