Eosinophilic esophagitis often underdiagnosed, misinterpreted
MedWire News: Eosinophilic esophagitis (EoE) is frequently underdiagnosed due to lack of clinical suspicion, failure to biopsy, and histopathologic misinterpretation, results of a UK study show.
Primary EoE is marked by dysphagia, food bolus obstruction, and chest pain, in association with esophageal mucosal biopsies containing at least 15 intraepithelial eosinophils per high power field (eos/hpf) in one or more specimens.
Due to a belief that EoE can often be overlooked, a local protocol was introduced in January 2004 within the Northumbria National Health Service Trust that recommended all patients presenting to endoscopy with dysphagia have esophageal biopsies.
Stephen Attwood (North Tyneside Hospital, North Shields) and colleagues reviewed pathology records of all 67,840 gastroscopies performed in the trust between January 2001 and November 2008 for EoE.
Case notes were inspected to identify patients with a diagnosis of EoE in accordance with American Gastroenterology Association guidelines.
No cases were identified before introduction of the new protocol in 2004, after which time 23 patients were diagnosed by the multidisciplinary team, and a further 14 patients with EoE remained undiagnosed until highlighted by the current study. Nine of these patients had been mislabeled as having gastro-esophageal reflux disease (GERD), two mislabeled as candida infection, and three as normal.
The mean duration of symptoms before the diagnosis was 4 years (range, 4 months to 30 years).
Reasons for diagnostic failure and delay, which were multiple in some patients, included delayed request for endoscopy in dysphagia (49%); poor recognition of typical endoscopic appearances of EoE (16%); and failed recognition or recording of maximal eosinophil concentrations within biopsies (35%).
Other reasons for diagnostic failure and delay were clinical mislabelling as GERD (22%) or candida (13%); and histological mislabelling as GERD (19%), candida (5%), inflammation (8%), or Barrett's esophagus (3%).
"This case series clearly shows the benefit of educating the wider multidisciplinary team, including physicians, general surgeons, ear, nose, and throat surgeons, endoscopists, and pathologists regarding the presentation, endoscopic, and histological findings of EoE," Attwood and team comment in the European Journal of Gastroenterology & Hepatology.
As a further method of improving diagnosis on a national scale they also propose a disease register, which would help identify the true incidence of EoE and may encourage diagnostic enquiry in geographical areas where no cases have yet been identified.
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By Andrew Czyzewski