Eosinophilic esophagitis: red on microscopy, white on endoscopy

Background/aims: The presenting symptom of eosinophilic esophagitis, a chronic T(H)2-type inflammatory disease, is uniform dysphagia attacks. Histology reveals a dense mucosal infiltration with eosinophils. Unfortunately, endoscopic findings are often unremarkable or misleading. This study characterizes the endoscopic manifestations of eosinophilic esophagitis and analyzes the nature and clinical features of the frequently observed white alterations.

Methods: Thirty adult patients (22 males, 8 females; mean age 40.6 years) with previously confirmed EE prospectively underwent a structured interview, physical examination, laboratory tests and upper endoscopy with histomorphometric examination of the esophageal mucosa.

Results: On endoscopy, all patients showed mucosal abnormalities in the esophagus. Findings included an unspectacular loss of vascular pattern (93.3%) and white exudates (53.3%). Biopsies demonstrated significantly increased eosinophilia in the white exudates (108.4 vs. 14.0 cells/hpf). A significant correlation was found between white exudates and dysphagia frequency (<1 attack/week = 20%; >1 attack/week = 70%).

Conclusion: Eosinophilic esophagitis evokes at least 12 different signs resulting in an individually unique endoscopic pattern, but no disease-specific picture. White exudates correspond to foci of dense eosinophilic infiltration reflecting inflammatory activity and are associated with significantly more frequent dysphagia attacks. Both the lack of a typical endoscopic picture as well as the heterogeneity of the eosinophilic infiltration impede diagnosis.