Gastroenterology Practice Patterns Contribute to Missed Diagnoses of Eosinophilic Gastritis and Duodenitis

Abstract

Background and aims: Eosinophilic gastritis and eosinophilic duodenitis (EoG/EoD) are often misdiagnosed as functional gastrointestinal (GI) disorders. Consequently, patients with GI symptoms of EoG/EoD may not undergo the necessary steps for diagnosis. We studied gastroenterologists' evaluations of patients with chronic, unexplained, moderate-to-severe GI symptoms that were unresponsive to over-the-counter medications.

Methods: We performed a cross-sectional online survey of 202 board-certified gastroenterologists at office-based practices, community hospitals, or academic institutions. Respondents had been in active clinical practice for 3-35 years post-residency training, spent most of their time on direct patient care, managed ≥1 patient with irritable bowel syndrome and/or functional dyspepsia, and performed ≥1 endoscopy per month. Responses were analyzed to identify barriers to EoG/EoD diagnosis and management.

Results: Respondents managed a mean of 1880 patients per year; the most common diagnoses were functional dyspepsia (36%) and gastroesophageal reflux disease (19%). Mean proportions of patients who underwent upper endoscopy ranged from 42% to 84%. Biopsies were collected from >90% of patients with visible endoscopic mucosal abnormalities vs 42%-72% of patients with normal-appearing mucosae. Approximately 20% of respondents collected only 1-2 biopsies from each site of the GI tract. Only 30% routinely requested pathologists to count eosinophils, and nearly 40% had no histologic threshold for EoG/EoD diagnosis.

Conclusion: Gastroenterologists vary in their evaluation of patients with chronic, unexplained moderate-to-severe GI symptoms. Limited gastric and duodenal biopsy collection, particularly from normal-appearing mucosae, and failure to request tissue eosinophil counts might contribute to underdiagnosis of EoG/EoD. Availability and awareness of EoG/EoD diagnostic guidelines should improve detection in clinical practice.

Keywords: Eosinophil; Gastrointestinal; Misdiagnosed; Pathology; Symptoms.

Figure 1

Patient characteristics. (A) Diagnoses of respondents’ typical patients. (B) Mean percentage of patients diagnosed with each disorder perceived to be moderate-to-severe. EoE, eosinophilic esophagitis; EoG/EoD, eosinophilic gastritis and/or eosinophilic duodenitis; FD, functional dyspepsia; FGID, functional gastrointestinal disorder; GERD, gastroesophageal reflux disease; IBD, inflammatory bowel disease; IBS, irritable bowel syndrome.

Figure 2

Diagnostic approach. (A) Mean percentage of new patients with chronic, unexplained, moderate-to-severe symptoms unresponsive to over-the-counter medications who undergo these procedures within the first 6 months of their initial appointment. (B) Mean percentage of patients diagnosed with each condition who undergo EGD at any point during their care. EGD, esophagogastroduodenoscopy; FD, functional dyspepsia; GERD, gastroesophageal reflux disease; IBD, inflammatory bowel disease; IBS, irritable bowel syndrome.

Figure 3

Biopsy collection. (A) Percentage of respondents reporting levels of agreement with statements related to collection of biopsies during EGD, rated on a scale of 1 (completely disagree) to 7 (completely agree). (B) Mean percentage of patients from whom respondents collect esophageal, stomach, and duodenum biopsies based on mucosal appearance. (C) Percentage of respondents who report collecting each number of biopsies from the esophagus, stomach, and duodenum; the survey question required respondents to enter numerical, open-ended responses, which were grouped post hoc into the ranges shown. EGD, esophagogastroduodenoscopy.

Figure 4

Counting eosinophils in gastric and duodenal biopsies. (A) Percentage of respondents reporting levels of agreement with statements related to pathologists’ counting of eosinophils in gastric and duodenal biopsy specimens, rated on a scale of 1 (completely disagree) to 7 (completely agree). (B) Percentages of respondents reporting number of eosinophils per high-power field in biopsies that they use as thresholds for diagnosis of EoG/EoD; the question required respondents to enter numerical, open-ended responses, which were grouped post hoc into the ranges shown. EoG/EoD, eosinophilic gastritis and/or eosinophilic duodenitis.

Figure 5

Diagnosing and managing patients with EoG/EoD. (A) Percentages of respondents reporting the number of patients with EoG/EoD that they typically treat in a 12-month period. (B) Percentages of respondents reporting levels of agreement with statements about diagnosis and treatment of EoG/EoD on a scale of 1 (completely disagree) to 7 (completely agree). (C) Percentages of respondents ranking their perception of potential barriers related to the diagnosis of EoG/EoD on a scale of 1 (not at all a barrier) to 5 (extremely large barrier). (D) Percentage of respondents reporting their level of satisfaction with treatment options for gastrointestinal disorders on a scale of 1 (not at all satisfied) to 7 (extremely satisfied). EoG/EoD, eosinophilic gastritis and/or eosinophilic duodenitis; FD, functional dyspepsia; GERD, gastroesophageal reflux disease; IBD, inflammatory bowel disease; IBS, irritable bowel syndrome.