Updated Diagnostic Guidelines for Eosinophilic Esophagitis: Outcomes From AGREE

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Criteria developed for the guidelines could be used in both clinical practice and research trials.
Criteria developed for the guidelines could be used in both clinical practice and research trials.

An international consensus conference was recently convened to assess the evidence and apply evolving understanding and new insights to the diagnostic criteria previously established for pediatric and adult eosinophilic esophagitis (EoE).  The guidelines that were established as a result of this conference were recently published in Gastroenterology.

Although guidelines established in 2007 and updated in 2011 considered EoE and gastroesophageal reflux disease (GERD) to be mutually exclusive conditions, recent clinical experience has uncovered a shared complex relationship between the 2 entities. Therefore, the team of experts — including adult and pediatric gastroenterologists, allergists, and pathologists — conducted extensive assessment of the evidence in order to update the current diagnostic algorithm for EoE.

Three questions were identified in order to create the diagnostic criteria for EoE:

  1. What evidence exists to support the use of proton pump inhibitors (PPIs) for suspected EoE in children, adolescents, and adults?
  2. What mechanisms could explain resolution of esophageal eosinophilia by PPIs?
  3. What are the sensitivity and specificity of diagnostic tests for GERD?

PubMed was used to identify publications that identified 1 or more patients of any age with eosinophilic esophagitis who were treated with PPIs.  Teams with expertise in certain topics were established to review the literature.  The review process was conducted from January to April 2017, following which time a meeting was held on May 5, 2017, to discuss each team's findings and establish consensus.  At this meeting, all attendees agreed to remove the requirement of a PPI trial to distinguish EoE from GERD.

The following principles were outlined by the researchers for the updated EoE diagnostic criteria:

“First, because EoE was felt to be the same disease in children and adults and any age cut-off would be arbitrary, the criteria were crafted to be applicable to all ages. Second, there was an emphasis on removing the PPI as part of the diagnostic criteria. Third, we emphasized the need to evaluate for conditions that might contribute to esophageal eosinophilia rather than require their exclusion. For patients with reflux symptoms, this would allow EoE and GERD to coexist. Fourth, there was a requirement that the criteria be operationalized in a clinically useful way. Finally, the criteria would need to have utility in both clinical practice and research trials, and would need to be applicable to patients who had been diagnosed with EoE under prior guidelines. The other important principle was that EoE remains, as conceptually defined in the 2011 guidelines, a chronic, immune/antigen-mediated esophageal disease characterized clinically by symptoms related to esophageal dysfunction and histologically by eosinophil-predominant inflammation.”

Some of the recommendations identified in the guidelines include the following:

  • The practitioner should evaluate for endoscopic signs of EoE as well as alternative esophageal disorders.
  • In all cases where EoE is clinically possible, biopsy specimens from the esophagus should be obtained.
  • All patients with esophageal eosinophilia of ≥15 eosinophils per high-power field (~60 eos/mm2) should be further evaluated for non-EoE disorders that may contribute to esophageal eosinophilia.

“…the evidence suggests that in many cases PPI-REE [PPI-responsive esophageal eosinophilia] is indistinguishable from EoE, and PPIs are better classified as a treatment for esophageal eosinophilia that may be due to EoE than as a diagnostic criterion,” the authors stated. “These updated international consensus criteria reflect this concept. As the field continues to develop and the research questions identified during this process are answered, the criteria presented here will evolve in the context of new data and advances.”

Reference

Dellon ES, Liacouras CA, Molina-Infante J, et al. Updated international consensus diagnostic criteria for eosinophilic esophagitis: proceedings of the AGREE conference [published online July 12 2018]. Gastroenterology. doi: 10.1053/j.gastro.2018.07.009


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