INTRODUCTION:The diagnosis of Barrett's esophagus (BE) requires identification of goblet cells in esophageal columnar-lined epithelium. Forceps biopsies (FB) may miss goblet cells because of sampling error. In addition, pathologists may misidentify distended pseudogoblet cells as true goblet cells. Caudal-type homeobox transcription factor 2 (CDX2) and mucin 2 (MUC2) are molecules involved in BE pathogenesis. The utility of CDX2 and MUC2 immunohistochemistry is assessed in the diagnosis of BE. METHODS:We performed a prospective, community-based registry study of patients with gastroesophageal reflux disease undergoing endoscopy for BE screening. All patients underwent both FB and Wide Area Transepithelial Sampling with 3-Dimensional Computer Analysis (WATS3D). CDX2 and MUC2 immunohistochemistry was performed on WATS3D samples. We assessed concordance between CDX2 and MUC2 staining and goblet cells, on both WATS3D and FB. Operating characteristics of FB for diagnosing BE were calculated using MUC2 positivity and goblet cells on WATS3D as the gold standard. RESULTS:Of 35,265 patients enrolled, 11,040 (31.3%) met endoscopic criteria for BE. Of these, 8,464 (76.7%) were CDX2+ and 3,563 (32.3%) were MUC2+. Whereas there was almost perfect concordance between MUC2 positivity and goblet cells on WATS3D, only 65.4% of patients with goblet cells on FB were MUC2+ on WATS3D. When using MUC2+ and goblet cells on WATS3D as the reference standard, FB diagnosed BE with sensitivity of 46.3%, specificity 88.3%, positive predictive value 65.4%, and negative predictive value 77.5%. DISCUSSION:MUC2 immunohistochemistry may be more sensitive and specific for diagnosing BE than goblet cells by FB. FB misses approximately half of BE when using MUC2/WATS3D as an alternative gold standard. The addition of MUC2 immunohistochemistry may aid in the recognition of BE.

Background and Aims: While mental illness is common in eosinophilic esophagitis (EoE), it is unknown whether psychiatric diagnosis frequency has varied over time or impacts treatment outcomes. We aimed to determine time trends in psychiatric diagnoses in EoE and whether such diagnoses affect EoE treatment outcomes. Methods: In this retrospective cohort study of newly diagnosed EoE patients, medical records were examined to determine psychiatric diagnoses and psychoactive medication use. For patients who also had treatment with either a topical corticosteroid (tCS) or diet elimination and had a follow-up endoscopy with biopsy, histologic, endoscopic, and symptom responses were assessed. We evaluated time-trends in psychiatric diagnoses over >2 decades and compared tCS and diet elimination treatment response between patients with and without psychiatric diagnoses. Results: Of 1291 newly diagnosed patients with EoE, 29% had a concomitant psychiatric diagnosis (18% depression; 24% anxiety) and 25% were on psychiatric medications. Over the 2-decade study timeframe, there was a slight overall increase in psychiatric diagnoses. However, diagnoses spiked in 2020 to >50% during the coronavirus disease 2019 (COVID-19) pandemic. There was no worsening in response rates for those with psychiatric diagnoses for either tCS or diet elimination treatment. Conclusions: Psychiatric diagnoses demonstrate a slight increase in EoE over the past 2 decades, though rates spiked during the COVID-19 pandemic, substantiating the burden of depression and anxiety during this time. Interestingly, the presence of a psychiatric disorder did not impact treatment outcomes to either tCS or diet elimination, so either option is viable in EoE patients with these diagnoses.

Background and Aims:Though topical corticosteroids have long been used for the treatment of eosinophilic esophagitis (EoE), real-world data for the recently Food and Drug Administration-approved budesonide oral suspension (BOS) are lacking. We sought to determine the efficacy of BOS in a real-world cohort of EoE patients. Methods:We conducted a retrospective cohort study of patients with EoE who were treated with BOS. Baseline characteristics, history, and procedural data were extracted from the medical record. We assessed endoscopic, histologic, and symptomatic responses for the endoscopy immediately preceding and following 12 weeks of BOS. Results:We identified 145 EoE patients prescribed BOS at our center since 2024 (mean age 35.4 years; 60% male), of whom 111 (77%) ultimately obtained insurance approval and 94 (65%) were able to fill their prescription. Post-treatment data were available for 48 patients. Compared to before BOS treatment, post-BOS patients were more likely to achieve a histologic response at all thresholds (eg, 73% vs 19% for <15 eos/hpf; P < .001) and endoscopic response (64% vs 22% for EoE Endoscopic Reference Score ≤2; P < .001), with associated significant reductions in peak eosinophil count (15.0 ± 30.6 vs 66.7 ± 71.8; P < .001) and total EoE Endoscopic Reference Score (2.0 ± 1.9 vs 3.9 ± 2.2; P < .001). Global symptom improvement was reported in 78%. Conclusion:In this initial real-world cohort treated with the Food and Drug Administration-approved BOS, histologic response rates reflected those seen in BOS clinical trials. Symptoms and endoscopic findings improved in parallel. Because the majority of prescriptions could be filled and significant improvement was achieved compared to prior treatments, BOS should be considered when topical steroids are selected for EoE.

Esophageal food impaction (EFI) commonly occurs in eosinophilic esophagitis (EoE), but its spectrum of severity remains incompletely described. To determine whether presentation and outcomes of EoE differ based on type of EFI. Patients with newly diagnosed EoE were categorized by EFI type: those with transient symptoms, those with an emergency department (ED) visit but no esophagogastroduodenoscopy (EGD), and those with an ED visit and EGD. Patient, EoE, and treatment data were collected. We compared characteristics and treatment responses and used multinomial logistic regression to adjust for confounders. Of 814 EFI patients with EoE, 485 had transient symptoms (symptoms-only), 76 required only an ED visit (ED-only), and 253 required an ED visit and EGD (ED + EGD). Compared to symptoms-only, ED-only and ED + EGD were more likely to have rings (67

INTRODUCTION: Assessment of eosinophilic esophagitis (EoE) endoscopic findings is critical in determining disease activity. However, response thresholds for the EoE Endoscopy Reference Score (EREFS) are not definitively established. We assessed EREFS response thresholds in patients with EoE treated with topical corticosteroids. METHODS: We conducted a retrospective cohort study of newly diagnosed patients with EoE treated with topical corticosteroid who had a follow-up endoscopy with biopsy and EREFS assessed pretreatment/post-treatment. We explored endoscopic response thresholds. Patients with and without endoscopic response were compared and predictors of response were determined. Histologic and global symptom responses were determined and residual endoscopic findings calculated. RESULTS: Of 333 patients, 219 (68%), 206 (62%), 142 (43%), 70 (21%), 139 (42%), and 142 (43%) met response thresholds for EREFS ≤2, EREFS ≤2 with no components >1 nor worsening of any component, EREFS ≤1, EREFS = 0, inflammatory subscore = 0, and fibrostenotic subscore = 0, respectively. On multivariate analysis, lower body mass index (adjusted odds ratio [aOR]: 0.90; 95% confidence interval [CI]: 0.85–0.95), heartburn (aOR: 2.74; 95% CI: 1.37–5.48), and lower total baseline EREFS (aOR: 0.57; 95% CI: 0.29–0.71) independently predicted EREFS ≤2. After treatment, 74% with EREFS≤2 vs 23% with EREFS>2 ( P < 0.001) had histologic response at <15 eos/hpf. Endoscopic responders more frequently endorsed a global symptom response (89% vs 56%; P < 0.001) and had minimal residual endoscopic findings. Outcomes stratified for adults and children were comparable with the entire cohort. DISCUSSION: Post-treatment EREFS ≤2 was consistent with symptom and histologic response for the entire cohort. These data support EREFS ≤2 as a robust threshold to define endoscopic response.

BACKGROUND & AIMS:The Index of Severity for Eosinophilic Esophagitis (I-SEE) grades eosinophilic esophagitis (EoE) severity across several domains. We assessed associations between EoE features and severity by I-SEE at diagnosis, and baseline I-SEE and outcomes following topical corticosteroids (tCS). METHODS:We conducted a retrospective cohort study of newly diagnosed EoE patients. Data were extracted to complete the I-SEE at diagnosis. Disease activity was categorized as mild (I-SEE 1-6), moderate (I-SEE 7-14), or severe (I-SEE ≥15). We compared baseline characteristics by I-SEE category. We assessed if baseline I-SEE associated with treatment response in patients treated with tCS. RESULTS:Of 1312 patients, there were 657 (50%), 461 (35%), and 194 (15%) with mild, moderate, and severe disease by I-SEE, respectively. Baseline scores were similar for children (8.5 ± 6.6) and adults (8.8 ± 6.5) (P = .37). Compared with mild or moderate disease, patients with severe disease were younger (23.8 ± 19.8 years for severe vs 28.0 ± 19.7 years for mild vs 30.3 ± 17.0 years for moderate; P < .001), had lower body mass index (21.6 ± 7.1 kg/m2 vs 24.4 ± 7.0 kg/m2 vs 25.7 ± 6.8 kg/m2; P < .001), and had longer symptom length preceding diagnosis (9.3 ± 10.5 years vs 5.9 ± 7.5 years vs 7.2 ± 7.9 years; P < .001). The baseline category associated with tCS response, with severe patients less likely to have histologic response (49% vs 55% vs 64%; P = .03 for <15 eosinophils per high-power field) and symptomatic responses, while also having the highest post-treatment eosinophilic esophagitis endoscopic reference scores. CONCLUSIONS:I-SEE correlated with baseline features in a large EoE cohort, performed similarly in children and adults, and associated with post-treatment responses to tCS. These data support that I-SEE provides prognostic data and suggest that severe disease may benefit from intensive upfront management.

Eosinophilic esophagitis (EoE) is a chronic, inflammatory disease defined by esophageal symptoms and eosinophilic infiltration.1 The diagnostic delay in EoE is a risk factor for progression to fibrostenosis.2 A more detailed understanding of this diagnostic delay would inform efforts to address it.3 If certain patient populations are disproportionately impacted by a prolonged time from symptoms to diagnosis, targeted efforts could mitigate delay and prevent disease progression. However, whether there are diagnostic disparities in the United States remains unknown.4 We aimed to determine whether there are disparities in diagnostic delay for EoE by age, race, or other patient characteristics.

Untreated eosinophilic esophagitis (EoE) can result in the development of fibrostenosis over time, but there are few data on whether successful treatment in childhood decreases this risk as children with EoE transition to adulthood. To determine whether histologic response or endoscopic normalization after EoE treatment is associated with decreased development of fibrostenosis. Pediatric subjects were identified from a large EoE database at an academic referral center. Medical records were reviewed for the primary outcome of fibrostenosis, defined as esophageal stricture, narrowing, or dilation. We assessed the proportion of histologic responders and normal endoscopies at the first, second, and last esophagogastroduodenoscopy (EGD) on record following diagnosis. We created Kaplan–Meier curves to assess time to fibrostenosis and estimated hazard ratios using Cox proportional analysis. Among 166 patients, the mean age at diagnosis was 10.2 years. Over a mean follow-up time of 4.7 ± 4.5 years, patients had an average of 4.3 ± 4.2 EGDs. The percent of patients with fibrostenosis was 9