The prevalence and diagnostic utility of endoscopic features of eosinophilic esophagitis: a meta-analysis

Abstract

Background & aims: Endoscopic findings such as esophageal rings, strictures, narrow-caliber esophagus, linear furrows, white plaques, and pallor or decreased vasculature might indicate the presence of eosinophilic esophagitis (EoE). We aimed to determine the prevalence and diagnostic utility of endoscopic features of EoE.

Methods: We conducted a systematic review and meta-analysis. PubMed, EMBASE, and gastrointestinal meeting abstracts were searched to identify studies that included more than 10 patients with EoE and reported endoscopic findings. Pooled prevalence, sensitivity, specificity, and predictive values were calculated using random- and mixed-effects models.

Results: The search yielded 100 articles and abstracts on 4678 patients with EoE and 2742 without (controls). In subjects with EoE, the overall pooled prevalence was as follows: esophageal rings, 44%; strictures, 21%; narrow-caliber esophagus, 9%; linear furrows, 48%; white plaques, 27%; and pallor/decreased vasculature, 41%. Substantial heterogeneity existed among studies. Results from endoscopy examinations were normal in 17% of patients, but this number decreased to 7% when the analysis was limited to prospective studies (P < .05). Overall levels of sensitivity were modest, ranging from 15% to 48%, whereas levels of specificity were greater, ranging from 90% to 95%. Positive predictive values ranged from 51% to 73% and negative predictive values ranged from 74% to 84%.

Conclusions: There is heterogeneity among studies in the reported prevalence of endoscopic findings in patients with EoE, but in prospective studies at least 1 abnormality was detected by endoscopy in 93% of patients. The operating characteristics of endoscopic findings alone are inadequate for diagnosis of EoE. Esophageal biopsy specimens should be obtained from all patients with clinical features of EoE, regardless of the endoscopic appearance of the esophagus.

Figure 1

Flow diagram delineating the inclusion and exclusion of studies from the prevalence and operating characteristics analyses.

Figure 2

The effect of EoE prevalence on the positive and negative predictive values of esophageal rings for diagnosing EoE. The sensitivity and specificity of esophageal rings are held constant at 48% and 91%, respectively, (these are the values calculated with a random-effects meta-analysis in this study), the prevalence of EoE is varied on the x-axis, and the resulting PPV or NPV are noted on the y-axis.

Figure 3

Typical endoscopic findings of EoE. (A) Prominent and fixed esophageal rings and narrow caliber esophagus. (B) Subtle rings. (C) Rings and linear furrows, as well as mucosal pallor and decreased vasculature. (D) Linear furrows, mucosal pallor, and decreased vasculature. (E) Linear furrows and white plaques or exudates, as well as mucosal pallor and decreased vasculature.

Figure 3

Typical endoscopic findings of EoE. (A) Prominent and fixed esophageal rings and narrow caliber esophagus. (B) Subtle rings. (C) Rings and linear furrows, as well as mucosal pallor and decreased vasculature. (D) Linear furrows, mucosal pallor, and decreased vasculature. (E) Linear furrows and white plaques or exudates, as well as mucosal pallor and decreased vasculature.

Figure 3

Typical endoscopic findings of EoE. (A) Prominent and fixed esophageal rings and narrow caliber esophagus. (B) Subtle rings. (C) Rings and linear furrows, as well as mucosal pallor and decreased vasculature. (D) Linear furrows, mucosal pallor, and decreased vasculature. (E) Linear furrows and white plaques or exudates, as well as mucosal pallor and decreased vasculature.

Figure 3

Typical endoscopic findings of EoE. (A) Prominent and fixed esophageal rings and narrow caliber esophagus. (B) Subtle rings. (C) Rings and linear furrows, as well as mucosal pallor and decreased vasculature. (D) Linear furrows, mucosal pallor, and decreased vasculature. (E) Linear furrows and white plaques or exudates, as well as mucosal pallor and decreased vasculature.

Figure 3

Typical endoscopic findings of EoE. (A) Prominent and fixed esophageal rings and narrow caliber esophagus. (B) Subtle rings. (C) Rings and linear furrows, as well as mucosal pallor and decreased vasculature. (D) Linear furrows, mucosal pallor, and decreased vasculature. (E) Linear furrows and white plaques or exudates, as well as mucosal pallor and decreased vasculature.