Utility of gastric and duodenal biopsy sampling in adult eosinophilic esophagitis patients to rule out other gastrointestinal disorders

Abstract

Rationale: According to consensus guidelines, if eosinophilic esophagitis (EoE) is suspected, not only esophageal but also gastric and duodenal biopsy specimens should be sampled in order to exclude other generalized or eosinophilic gastrointestinal (GI) disorders, such as eosinophilic gastroenteritis or celiac disease. However, the diagnostic yield for this remains unclear. Aim: To assess the diagnostic yield of biopsy sampling from the stomach and duodenum in adult EoE patients to rule out generalized or eosinophilic GI disorders. Methods: A retrospective chart-review was conducted in untreated adult EoE patients that underwent upper endoscopy with biopsies sampled from the esophagus, stomach and duodenum. Standardized (electronic) case-report forms were used to extract clinical, endoscopic and histologic data. Results: In total, 93 adults (71% males, age 36.4 (interquartile range 28.4 À 49.1) years) with untreated EoE (!15 eosinophils/high-power-field) were included. Symptoms of dysphagia and food impaction were reported in 93% and 58%, respectively of the patients. Typical endoscopic EoE-features were present in 77 (85%) patients. The yield of routinely sampled gastric and duodenal biopsy specimens in our cohort was 3.6% (95% confidence interval: 2.6-4.8%) (n/N ¼ 1/93) for a relevant other generalized or eosinophilic GI diagnosis and 30% for other histological diagnosis such as non-specific or H. Pylori gastritis. In total, 62 (67%) patients presented with other GI symptoms and/or endoscopic abnormalities of the stomach and/or duodenumwhich both may be suggestive for other relevant GI conditions. The diagnostic yield for a relevant generalized or eosinophilic GI disorder in this subgroup was, 4.8% (95%CI 3.4 À 6.7%) (n/N ¼ 1/62). Conclusion: Gastric and duodenal biopsy specimens seem to have limited diagnostic value for the exclusion of generalized or eosinophilic GI disorders in adults with EoE. KEY POINTSEvidence is lacking on the diagnostic value of additional biopsies sampled form the stomach and duodenum to rule out other relevant generalized or eosinophilic gastrointestinal (GI) disorders. The yield of gastric and duodenal biopsies routinely sampled in our cohort was 3.6% for a relevant other generalized or eosinophilic GI diagnosis and 30% for other histological diagnosis such as non-specific or H. Pylori gastritis. The diagnostic yield for a relevant generalized or eosinophilic GI disorder in the subgroup of patients (67%) presenting with other GI symptoms and/or endoscopic abnormalities of the stomach and/or duodenum -which both may be suggestive for other relevant GI conditions was, 4.8%. Gastric and duodenal biopsy specimens seem to have limited diagnostic value for the exclusion of generalized or eosinophilic GI disorders in adults with EoE.

Clinical Characteristics of Children with Eosinophilic Esophagitis and Bulbar Duodenitis

“…We report on 33 pediatric patients having EoE and BD without an identifiable cause such as H. pylori infection, NSAID use, celiac disease, IBD, or peptic injury. The duodenal histology in these cases most commonly showed a mixed inflammatory infiltrate, and all presented with visually abnormal duodenal bulb mucosa—differing from prior published reports (5–7). BD also occurred most commonly with active EoE, though it is not immediately clear how these 2 findings are etiologically linked.…”

“…Within this group, a cause could not be determined for 10 of 22 patients (45%) (6). Other studies have reported similar incidences of duodenitis with and without an identifiable cause in adults with EoE (5,7). Our study adds to these reports, by focusing further on duodenitis without an identifiable cause that affects only the duodenal bulb and not the distal duodenum.…”

S2k-Leitlinie Gastroösophageale Refluxkrankheit und eosinophile Ösophagitis der Deutschen Gesellschaft für Gastroenterologie, Verdauungs- und Stoffwechselkrankheiten (DGVS) – März 2023 – AWMF-Registernummer: 021–013

“…Bei Erstdiagnose sollten auch immer Biopsien aus Magen und Duodenum entnommen werden, auch wenn fehlende Symptome oder endoskopische Auffälligkeiten das Vorhandensein einer eosinophilen Gastroenteritis unwahrscheinlich machen 587 588 . Einer aktuellen retrospektiven Untersuchung von 93 EoE-Patienten mit typischer klinischer Präsentation zufolge lag der diagnostische Gewinn im Hinblick auf einer relevanten eosinophilen Beteiligung des Magens oder Duodenums bei 3,6 % 589 .…”

Endoscopic Diagnosis of Eosinophilic Esophagitis: Basics and Recent Advances

“…In the absence of gastroenteritis-like symptoms or apparent endoscopic abnormalities in the stomach or the duodenum, gastroduodenal biopsies seem not to be necessary, at least in adult patients because esophageal involvement of eosinophilic gastroenteritis is unlikely [ 112 , 113 ].…”