It can be a challenge for clinicians to distinguish Eosinophilic oesophagitis (EoE) from gastro-oesophageal reflux disease (GERD) patients due to overlapping symptoms. This study identified a simple marker set, combining clinical features and a blood test, that not only showed excellent ability to predict EoE – it could also distinguish EoE from GERD.
What is EoE?
- Eosinophilic esophagitis is a chronic, allergic inflammatory disease of the esophagus (the tube connecting the mouth to the stomach). It occurs when a type of white blood cell, the eosinophil, accumulates in the esophagus and persists despite acid-blocking medicine.1
What is GERD?
- Gastroesophageal reflux disease (GERD) happens when a muscle at the end of your esophagus does not close properly.
- This allows stomach contents to leak back, or reflux, into the esophagus and irritate it.2
EoE 3 and GERD 4 are conditions that have an association with celiac disease.
Clinical Symptom Tool That Raises the Index of Suspicion for Eosinophilic Oesophagitis (EoE) in Adults and Drives Earlier Biopsy for Definitive Diagnosis
Background Eosinophilic oesophagitis (EoE) and gastro-oesophageal reflux disease (GERD) present with overlapping symptomatology and it is challenging to distinguish EoE from GERD clinically before endoscopy.
The diagnosis of EoE still represents a major challenge, especially against the background of the more highly prevalent GERD and its overlapping clinical symptoms.
A recently published calculation indicated that patients with EoE have an estimated annual health care cost of up to $1.4 billion in the USA; it may reasonably be expected that earlier diagnosis could reduce these costs.
Aim To investigate the prognostic value of a set of clinical symptoms and laboratory values in patients with EoE and GERD.
The analysis of demographic variables revealed clear differences between the EoE and GERD patients.
- The EoE patients were significantly younger and were more likely to be male.
- All clinical variables differed significantly between the two groups. (except for the symptoms ‘weight loss’ and ‘chest pain with or without swallowing/odynophagia’)
- Atopic co-morbidities also differed: in the EoE group, allergic diseases were reported significantly more frequently (75% of patients) than in the GERD group (13%), and the detailed history of atopic disorders showed significant differences for all the allergic diatheses. [a tendency to suffer from a particular medical condition]
- Significant differences were also seen for peripheral eosinophilia, in respect of both the number of patients affected and the absolute value.
- IgE levels were elevated significantly more frequently in EoE than in GERD, and accordingly the IgE concentrations also differed significantly.
- Use of PPI did not differ significantly between the two groups.
It should be mentioned here that all the EoE patients in our specialized out-patient department had already been treated with a PPI by their physician and had not responded to this either clinically or histologically, so that PPI-REE was excluded.
More detailed examination of these patients revealed that they had been told they were suffering from heartburn, while in fact – as closer questioning revealed – these EoE patients did not have the typical symptoms of heartburn. For this reason, we have replaced the term ‘PPI-refractory heartburn’ by ‘PPI-refractory symptoms’ in our routine medical workup.
Initial set of 10 markers reduced to four parameters:
- history of atopy [Atopy refers to the genetic tendency to develop allergic diseases such as allergic rhinitis, asthma and atopic dermatitis (eczema). Atopy is typically associated with heightened immune responses to common allergens, especially inhaled allergens and food allergens.]
- history of food impaction
- PPI- refractory symptoms
- either IgE or peripheral eosinophilia [blood eosinophilic leukocytes]
The reduced sets showed excellent ability to predict EoE and distinguish EoE from GERD.
Both sets were similarly capable to implement peripheral eosinophilia and IgE in respect to their individual contributions to the proposed scoring model; no significant difference was seen according to the criterion of AUC. (This observation is important for clinical practice, as a complete blood count, including peripheral eosinophils, is easier, quicker and cheaper than an IgE determination-meaning that the marker set including peripheral eosinophilia is in favour because of its rapid availability before performance of EGD [Esophagogastroduodenoscopy]
The other three markers in the set (PPI-refractory symptoms, history of food impaction, history of atopy) are easily recorded as part of the patient’s medical history, and they differed significantly between the two patient groups.
Our results show that a simple marker set, combining clinical features and a laboratory variable (either peripheral eosinophilia or IgE), is able to help distinguish between EoE and GERD patients, in the absence of EGD, with high accuracy.
This is of practical importance, as EoE is often prone to long diagnostic delays owing to the lack of clinical distinguishing characteristics of EoE and GERD resulting in improper biopsy technique during EGD.
In our study, we were able to identify a constellation of clinically relevant predictive markers that allow an initial distinction to be made between EoE and GERD on the basis of clinical observations alone. Our model can identify EoE accurately, and it can also reliably screen out non-EoE cases. Thus, if the marker constellation indicates that a patient may have EoE, then the physician should undergo an EGD with adequate biopsy technique to ensure definitive diagnosis of EoE.
We have developed a simple clinical and laboratory-based marker set that is able to help reliably distinguish between EoE and GERD before oesophagogastroduodenoscopy; the criteria are easily applied and they have a high predictive power.
The use of our model may be expected to lead to earlier EGDs with stepwise biopsies that will definitively make the diagnosis of EoE. Moreover, it may lead to the avoidance or reduction of complications through the earlier adoption of anti-inflammatory treatment.
- 1. What is EoE? http://apfed.org/about-ead/egids/eoe/
- 2. What is GERD? https://medlineplus.gov/gerd.html
- 3. Association between Celiac Disease and EoE http://www.medscape.com/viewarticle/807926
- 4. Acid Reflux linked to Celiac Disease https://www.glutenfreesociety.org/acid-reflux-linked-to-gluten-intolerance/