Diffuse esophageal eosinophilia is associated with increased endoscopic severity and topical steroid non-response in...

Variability of esophageal eosinophil distributions and its impact on disease presentation and treatment outcomes in eosinophilic esophagitis (EoE) is unclear. We aimed to determine whether isolated proximal or distal involvement differs from diffuse involvement in EoE presentation and treatment outcomes.

This retrospective cohort study analyzed patients of all ages with newly diagnosed EoE from the UNC EoE Clinicopathologic database. Patients were classified as distal esophagus-only (≥15 eos/hpf), proximal-only (≥15 eos/hpf), and diffuse involvement (≥15 eos/hpf in both regions). Outcomes included histologic response (<15, ≤6, and <1 eos/hpf), global symptomatic response, and endoscopic response after treatment. Baseline characteristics and post-treatment response were compared between patients with localized and diffuse eosinophil involvement.

Of 888 cases of EoE, eosinophil counts were higher in the distal (54.8±44.7) versus proximal esophagus (44.0±40.1; p<0.001). Diffuse involvement (n=623; 70%) was associated with more inflammatory endoscopic findings and higher mean EREFS (4.0±1.8, p<0.001) compared to those with proximal (2.8±1.8) and distal involvement (2.7±1.6). Strictures and worse disease severity (Index of Severity for EoE) were also more frequent in diffuse disease. After topical corticosteroid treatment (n=395), patients with diffuse disease had reduced histologic response (at all thresholds) and endoscopic response compared to those with localized disease.

EoE patients with diffuse esophageal eosinophilic involvement had greater baseline disease severity and decreased histologic and endoscopic treatment response to topical corticosteroids than those with localized disease. Diffuse disease involvement could be an important marker for risk stratification and therapeutic decision-making in EoE disease management.