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It takes one meeting to increase awareness of eosinophilic esophagitisReferring to Krarup AL et al. p. 15–24
Eosinophilic esophagitis (EoE) is a chronic food allergen-driven condition of the esophagus, resulting in tissue remodeling with fibrosis and ultimately strictures in a considerable proportion of patients if left untreated . Since its first description in the early nineties, the management of EoE has changed significantly, from short, intermittent courses of corticosteroids to chronic maintenance therapy, similarly to the treatment paradigms in other chronic inflammatory conditions such as allergic asthma or inflammatory bowel disease. Current guidelines recommend chronic treatment with a proton-pump inhibitor, low-dose swallowed topical corticosteroids, or elimination diets . Patients under maintenance therapy were more likely to achieve clinical, endoscopic, and histologic remission and had a reduced need for endoscopic dilations for esophageal strictures . However, a correct and timely diagnosis is the critical first step in the management of EoE.
“The study underscores that biopsies should be taken in all patients with suggestive symptoms, even if the macroscopic appearance is normal.”
The reported incidence and prevalence of EoE has been increasing worldwide over the past two decades, with the current prevalence reaching 0.5 to 1 per 1000 . Even if this is partly a true rise in disease burden, an increased knowledge and awareness by both endoscopists and pathologists also contributes to these increasing numbers . Evidently, it comes as no surprise that the more biopsies taken in patients with dysphagia, the more cases of EoE will be diagnosed . Current guidelines recommend taking at least six biopsies at two different levels in the esophagus to achieve a maximum diagnostic yield . Unfortunately, adherence to diagnostic guidelines is generally poor in nonexpert centers, with low biopsy rates or low numbers of biopsies taken in symptomatic patients  .
In this issue of Endoscopy, Krarup et al. report on a quality improvement study aimed at increasing the diagnostic yield of EoE in the North Denmark Region . Before the project, the prevalence of EoE was below 1/100 000 inhabitants, which is considerably less than the prevalence reported in the literature by expert centers . A regional consensus meeting was organized in 2011, to which all heads of endoscopy units were invited, with a high participation rate of 82 %. The goal of the meeting was twofold: to provide information on the diagnostic management of EoE and to reach a consensus on a diagnostic protocol. The “4 – 14 – 4” rule was accepted as the consensus statement, recommending four biopsies at 4 and 14 cm above the esophagogastric junction in all patients with suggestive symptoms. In addition, the pathologists were stimulated to include a statement that > 15 eosinophils/high-power field, the international histologic criterium to date, may indicate EoE. The authors analyzed biopsy rates and diagnostic yield before (2007 – 2010) and after (2012 – 2017) the consensus meeting based on the analysis of the Danish national registry.
In the 6 years after the intervention, a 50-fold increase in the histologic diagnosis of esophageal eosinophilia was observed, which is much higher than the expected “real” increase of the disease incidence and most likely related to a change in practice. Indeed, the number of biopsies per patient almost doubled, especially because the proximal esophagus was also biopsied according to the consensus protocol. Intriguingly, and actually shockingly, of those patients with EoE, 81 % had previously undergone at least one endoscopy without biopsies, and 10 % had even undergone five or more endoscopies. From the data it cannot be concluded whether the increased diagnostic yield of EoE is related to the improved biopsy protocol or a better detection and registration by the pathologist, or – most likely – a combination of both. The impact of the consensus meeting was considerably more pronounced than the publication of regional and national EoE guidelines.
The study underscores that biopsies should be taken in all patients with suggestive symptoms, even if the macroscopic appearance is normal. Surprisingly, a normal endoscopic appearance of the esophagus was described in a third of the patients with esophageal eosinophilia, which is considerably higher than the 3 % – 10 % in expert series , and was most likely related to a lack of experience with the typical, but sometimes subtle, endoscopic signs of EoE. The distribution of images representing the typical endoscopic signs of EoE after the consensus meeting had no effect on the endoscopic diagnosis. None of the endoscopists used a systematic, validated endoscopic scoring system such as the Eosinophilic Esophagitis Reference Score . However, because of the limited information on symptoms, it is unclear which patients with esophageal eosinophilia suffered from EoE or gastroesophageal reflux disease, as the distinction was only based on the presence or absence of erosive esophagitis and Barrett’s esophagitis, which is not in agreement with the current diagnostic guidelines.
Krarup et al. are to be commended for their important work showing that an intervention as simple as a 2-hour consensus meeting followed by dissemination of information sheets, can lead to a dramatic change in practice with a real impact on everyday clinical care. It would be of interest to use the same paradigm to improve the uptake of other best practices as well, including the use of endoscopic scores in EoE.
17 December 2020 (online)
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