An Evaluation of the Quality of Esophageal Biopsies in Patients with Eosinophilic Esophagitis

Abstract

Introduction: Eosinophilic esophagitis (EoE) is a clinicopathologic diagnosis based on the presence of ≥15 eosinophils per high power field (hpf) in the epithelium. Additional changes include microabscesses, lamina propria (LP) papillae elongation, basal zone hyperplasia, intercellular edema, and LP fibrosis. Recent studies have shown the importance of subepithelial fibrosis as this correlates with clinical and endoscopic findings of EoE, disease duration and response to therapy. We sought to determine the adequacy of esophageal biopsies, defined as the presence of LP, among patients with EoE. Methods: This was a single-center, retrospective, observational study at a tertiary referral center. The pathology database was interrogated to identify pathology records from 2014-2015 that contained ≥15 eosinophils/hpf. All records were reviewed by one expert GI pathologist for the presence of lamina propria. We investigated factors that could influence acquisition of deeper esophageal biopsies including type of sedation, trainee involvement, procedure duration and seniority of attending endoscopist. Results: We reviewed 119 pathology records that were contributed by 109 patients. Within the pathology records, 244 esophageal biopsies were reviewed and classified by location (proximal, distal, and other; note that a pathology record could contribute multiple location biopsies). Only 98 biopsies had the presence of LP (40%). Breakdown according to location: proximal biopsies 25/66 (38%); distal biopsies 34/90 (38%); and other biopsies 39/88 (44%) had the presence of LP. Univariable generalized linear mixed models were used to estimate the odds of a higher number of LP biopsies. Patient demographics, trainee involvement, seniority of attending endoscopist, sedation used, and procedure time were not associated with odds of a higher number of LP biopsies. When analyzed by location of biopsies, senior attending physicians (defined as > 3 years in practice) were 3.74 (95% CI: 1.45 - 9.65) times as likely to obtain a positive distal biopsy with LP when compared to junior attendings (p = 0.01). Conclusion: The majority of biopsies did not contain LP. Senior attendings were more likely to obtain quality distal biopsies. Duration of procedure, sedation type, and trainee involvement did not affect depth of biopsy. As esophageal biopsy remains the gold standard for monitoring disease activity, quality of mucosal sampling is essential to providing accurate information to guide clinical management.395_A Figure 1. Odds of a higher count of lamina propria biopsies395_B Figure 2. Odds of a positive LP on distal biopsy