Criteria

Consensus diagnostic guidelines for eosinophilic esophagitis[1][2][3][4][80][83]

These criteria are based on guidelines and include clinical and pathologic criteria:

  • Symptoms of esophageal dysfunction. This is the clinical criterion. Symptoms include dysphagia, food impaction, heartburn, chest pain, regurgitation, vomiting. In children, abdominal pain and failure to thrive are also seen.

  • ≥15 eosinophils per high-power microscopy field (or ≥15 eosinophils per 0.3 mm²) on esophageal biopsy. This is the pathologic criterion. The eosinophilia must be isolated to the esophagus.

  • Exclusion of other causes. Other causes of systemic and esophageal eosinophilia must be evaluated. Gastroesophageal reflux disease (GERD) is the principal disease entity confused with EoE.

  • The relationship between GERD and EoE may be bidirectional. Patients with EoE achieving clinical and/or histologic remission on proton-pump inhibitor (PPI) therapy are part of the EoE continuum. Nonetheless, they may also have an element of GERD, and they may have acid hypersensitivity as a consequence of their EoE, accounting for part of their response to the PPI.

Consensus clinical severity index for eosinophilic esophagitis​[98]

These criteria reflect EoE's key clinicopathologic features in three domains:

Symptoms and complications

  • Symptoms

    • Weekly (1 point)

    • Daily (2 points)

    • Multiple times per day or disrupting social functioning (4 points)

  • Complications

    • Food impaction with emergency department visit or endoscopy (patient ≥18 years) (2 points)

    • Food impaction with emergency department visit or endoscopy (patient <18 years) (4 points)

    • Hospitalization due to EoE (4 points)

    • Esophageal perforation (15 points)

    • Malnutrition with body mass <5th percentile or decreased growth trajectory (15 points)

    • Persistent inflammation requiring elemental formula, or systemic corticosteroid, or immunomodulatory treatments (including biologics, azathioprine/mercaptopurine, or other immune-targeted treatments) (15 points)

Inflammatory features

  • Endoscopy (edema, furrows, and/or exudates)

    • Localized (1 point)

    • Diffuse (2 points)

  • Histology

    • 15-60 eosinophils/high-power field (1 point)

    • >60 eosinophils/high-power field (2 points)

    • Note UK guidelines recommend using 0.3 mm² instead of high-power field (the standard high-power field is 0.3 mm²)

Fibrostenotic features

  • Endoscopy (rings, strictures)

    • Present, but endoscope passes easily (1 point)

    • Present, but requires dilation or a snug fit when passing a standard endoscope (2 points)

    • Cannot pass standard upper endoscope; repeated dilations (in an adult ≥18 years); or any dilation (in a child <18 years) (15 points)

  • Histology

    • Basal zone hyperplasia or lamina propria (LP) fibrosis (or dyskeratotic epithelial cell/surface epithelial alteration if no LP) (2 points)

Eosinophilic esophagitis severity: 1-6 points = mild; 7-14 points = moderate; ≥15 points = severe

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