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Clinical Features Distinguish Eosinophilic and Reflux-induced Esophagitis

Mulder, Daniel J.*; Hurlbut, David J.; Noble, Angela J.; Justinich, Christopher J.§

Journal of Pediatric Gastroenterology & Nutrition: March 2013 - Volume 56 - Issue 3 - p 263–270
doi: 10.1097/MPG.0b013e3182794466
Original Articles: Gastroenterology

Background and Objectives: : Diagnosing eosinophilic esophagitis (EoE) depends on intraepithelial eosinophil count of ≥15 eosinophils per high-power field (HPF); however, differentiating EoE from gastroesophageal reflux disease (GERD) continues to be a challenge because no true “criterion standard” criteria exist. Identifying clinical and endoscopic characteristics that distinguish EoE could provide a more comprehensive diagnostic strategy than the present criteria. The aim of the study was to determine symptoms and signs that can be used to distinguish EoE from reflux esophagitis.

Methods: Adult and pediatric patients with EoE were identified by present diagnostic guidelines including an esophageal biopsy finding of ≥15 eosinophils/HPF. Patients with GERD were age-matched one to one with patients with EoE. Clinical, endoscopic, and histologic information at the time of diagnosis was obtained from the medical record and compared between pairs by McNemar test. A conditional logistic regression model was created using 6 distinguishing disease characteristics. This model was used to create a nomogram to differentiate EoE from reflux-induced esophagitis.

Results: Patients with EoE were 75% men and 68% had a history of atopy. Many aspects of EoE were statistically distinct from GERD when controlling for age. Male sex, dysphagia, history of food impaction, absence of pain/heartburn, linear furrowing, and white papules were the distinguishing variables used to create the logistic regression model and scoring system based on odds ratios. The area under the curve of the receiver-operator characteristic curve for this model was 0.858.

Conclusions: EoE can be distinguished from GERD using a scoring system of clinical and endoscopic features. Prospective studies will be needed to validate this model.

*Department of Anatomy and Cell Biology

Department of Pathology and Molecular Medicine

Department of Pediatrics

§Departments of Anatomy and Cell Biology, Pediatrics, Physiology and Medicine, Gastrointestinal Diseases Research Unit, Queen's University, Kingston, Ontario, Canada.

Address correspondence and reprint requests to Dr C. Justinich, Watkins 3, Rm 4-316, 76 Stuart St, Kingston, ON K7L 2V7, Canada (e-mail:

Received 10 July, 2012

Accepted 15 October, 2012

This article has been developed as a Journal CME Activity by NASPGHAN. Visit to view instructions, documentation, and the complete necessary steps to receive CME credit for reading this article.

The study was funded by Physicians’ Services Incorporated (PSI) Grants PSI-05–21 and PSI-09–02.

The authors report no conflicts of interest.

Copyright 2013 by ESPGHAN and NASPGHAN