Is it advised to take biopsies in an endoscopic normally appearing oesophagus to exclude an eosinophilic oesophagitis in children?

OBJECTIVES AND STUDY: Eosinophilic oesophagitis (EE) generally presents with reflux like symptoms, a specific endoscopic appearance and a histological extensive infiltration of eosinophils in the oesophagus. Some individuals can have a normal endoscopic appearance of the oesophagus making histology the only reliable diagnostic tool. We performed a prospective study to look for the presence of histological EE (HEE) in normally appearing oesophagus of children with gastro-oesophageal reflux symptoms. METHODS: One hundred and forteen children (56 boys) with a mean age of 8 years (0.5-17 years) presenting with gastro-oesophageal reflux symptoms underwent a fibroduodenoscopy with forceps biopsies taken at the distal (DOB) and proximal (POB) oesophagus between January and December 2010. Endoscopic appearance of the oesophagus was suggestive for EE when longitudinal furrows or vertical lines and/or horizontal rings and/or exudate were present. Refluxoesophagitis (RE) was defined according to the Los Angeles classification. A cut-off of 20 eosinophils per high power field was used to differentiate histological RE (HRE) from HEE (>20/HPF). RESULTS: Seven children had an endoscopic appearance of EE: DOB and POB confirmed HEE in 3/7, showed a HRE in 1/7 and a mycosis in 1/7, and were normal in 2/ 7 patients. Thirty-five children had an endoscopic appearance of RE: DOB and POB were normal in 29/35, showed a HRE in 6/35 and a HEE in 0/35 patients. Six patients had an endoscopic appearance of combined EE and RE: DOB and POB confirmed HEE in 1/6, showed a HRE in 2/6 and were normal in 3/6 patients. Finally, the endoscopic appearance of the oesophagus was normal in 66 patients: DOB and POB were normal in 49/68, showed a HRE in 17/68 and a HEE in 0/68 patients. CONCLUSIONS: The diagnosis of eosinophilic oesophagitis was never made by oesophageal biopsies in an endoscopic normally appearing oesophagus in children with gastro-oesophageal reflux symptoms.