Comparison of different biopsy forceps models for tissue sampling in eosinophilic esophagitis

Background and aims: Eosinophilic esophagitis (EoE) is a mixed inflammatory and fibrostenotic disease. Unlike superficial inflammatory changes, subepithelial fibrosis is not routinely sampled in esophageal biopsies. This study aimed to evaluate the efficacy and safety of deep esophageal sampling with four different types of biopsy forceps.

Patients and methods: In this cross-sectional study, esophageal biopsies were taken in 30 adult patients by one expert endoscopist. Biopsies sampled from distal esophagus using a static jaw forceps (Olympus, FB-11K-1) were compared with proximal biopsies sampled with static jaw (Olympus, FB-45Q-1), alligator jaw (Olympus, FB-210K), and large-capacity forceps (Boston Scientific, Radial Jaw 4). One pathologist calculated the surface area of epithelial and subepithelial layers in hematoxylin and eosin (H&E)-stained biopsies.

Results: Subepithelial tissue was acquired in 97 % (static jaw FB-11K-1), 93 % (static jaw FB-45Q-1), 80 % (alligator jaw), and 55 % (large-capacity) of samples. Median (interquartile [IQR]) ratios of surface area of epithelial to subepithelial tissue were: static jaw FB-45Q-1, 1.07 (0.65 – 4.465); static jaw FB-11K-1, 1.184 (0.608 – 2.545); alligator jaw, 2.353 (1.312 – 4.465); and large-capacity, 2.71 (1.611 – 4.858). The static jaw models obtained a larger surface area of subepithelial tissue compared with the alligator jaw (P < 0.001 and P = 0.037, for FB-11K-1 and FB-45Q-1, respectively) and the large-capacity forceps (P < 0.001, for both static jaw models). No esophageal perforations occurred.

Conclusions: The static jaw forceps models allowed sampling of subepithelial tissue in > 90 % of biopsies and appear to be superior to alligator or large-capacity forceps in sampling larger amounts of subepithelial tissue.

^* These authors contributed equally.

• References

• 1 Liacouras CA, Furuta GT, Hirano I et al. Eosinophilic esophagitis: updated consensus recommendations for children and adults. J Allergy Clin Immunol 2011; 128: 3-20
• 2 Furuta GT, Katzka DA. Eosinophilic esophagitis. N Engl J Med 2015; 373: 1640-1648
• 3 Giriens B, Yan P, Safroneeva E et al. Escalating incidence of eosinophilic esophagitis in Canton of Vaud, Switzerland, 1993–2013: a population-based study. Allergy 2015; 70: 1633-1639
• 4 Riou PJ, Nicholson AG, Pastorino U. Esophageal rupture in a patient with idiopathic eosinophilic esophagitis. Ann Thorac Surg 1996; 62: 1854-1856
• 5 Saffari H, Peterson KA, Fang JC et al. Patchy eosinophil distributions in an esophagectomy specimen from a patient with eosinophilic esophagitis: implications for endoscopic biopsy. J Allergy Clin Immunol 2012; 130: 798-800
• 6 Fox VL, Nurko S, Teitelbaum JE et al. High-resolution EUS in children with eosinophilic “allergic” esophagitis. Gastrointest Endosc 2003; 57: 30-36
• 7 Straumann A, Conus S, Degen L et al. Long-term budesonide maintenance treatment is partially effective for patients with eosinophilic esophagitis. Clin Gastroenterol Hepatol 2011; 9: 400-409
• 8 Fontillon M, Lucendo AJ. Transmural eosinophilic infiltration and fibrosis in a patient with non-traumatic Boerhaave’s syndrome due to eosinophilic esophagitis. Am J Gastroenterol 2012; 107: 1762
• 9 Aceves SS, Newbury RO, Dohil R et al. Esophageal remodeling in pediatric eosinophilic esophagitis. J Allergy Clin Immunol 2007; 119: 206-212
• 10 Mishra A, Wang M, Pemmaraju VR et al. Esophageal remodeling develops as a consequence of tissue specific IL-5-induced eosinophilia. Gastroenterology 2008; 134: 204-214
• 11 Schoepfer AM, Safroneeva E, Bussmann C et al. Delay in diagnosis of eosinophilic esophagitis increases risk for stricture formation, in a time-dependent manner. Gastroenterology 2013; 145: 1230-1236
• 12 Kagalwalla AF, Akhtar N, Woodruff SA et al. Eosinophilic esophagitis: epithelial mesenchymal transition contributes to esophageal remodeling and reverses with treatment. J Allergy Clin Immunol 2012; 129: 1387-1396
• 13 Safroneeva E, Straumann A, Coslovsky M et al. Symptoms have modest accuracy in detecting endoscopic and histologic remission in adults with eosinophilic esophagitis. Gastroenterology 2016; 150: 581-590
• 14 Sharaf RN, Shergill AK. ASGE Standards of Practice Committee et al. Endoscopic mucosal tissue sampling. Gastrointest Endosc 2013; 78: 216-224
• 15 Schoepfer AM, Panczak R, Zwahlen M et al. How do gastroenterologists assess overall activity of eosinophilic esophagitis in adult patients?. Am J Gastroenterol 2015; 110: 402-414
• 16 Bussmann C. Requirements of the pathologist to the endoscopist (biopsy sampling). Dig Dis 2014; 32: 74-77
• 17 Dellon ES, Gonsalves N, Hirano I et al. ACG clinical guideline: evidence based approach to the diagnosis and management of esophageal eosinophilia and eosinophilic esophagitis. Am J Gastroenterol 2013; 108: 679-692
• 18 Molina-Infante J, Bredenoord AJ, Cheng E et al. Proton pump inhibitor-responsive oesophageal eosinophilia: an entity challenging current diagnostic criteria for eosinophilic oesophagitis. Gut 2016; 65: 524-531
• 19 Schoepfer AM, Panczak R, Zwahlen M et al. How do gastroenterologists assess overall activity of eosinophilic esophagitis in adult patients?. Am J Gastroenterol 2015; 110: 402-414
• 20 Hirano I, Moy N, Heckman MG et al. Endoscopic assessment of the oesophageal features of eosinophilic esophagitis: validation of a novel classification and grading system. Gut 2013; 62: 489-495
• 21 Bussmann C, Straumann A. Eosinophilic esophagitis: the diagnostic contribution of pathology. Pathologe 2013; 34: 110-117
• 22 Schoepfer AM, Hirano I, Katzka D. Eosinophilic esophagitis: overview of clinical management. Gastroenterol Clin North Am 2014; 43: 329-344
• 23 Rieder F, Nonevski I, Ma J et al. T-helper 2cytokines, transforming growth factor β1, and eosinophil products induce fibrogenesis and alter muscle motility in patients with eosinophilic esophagitis. Gastroenterology 2014; 146: 1266-1277
• 24 Straumann A, Bussmann C, Zuber M et al. Eosinophilic esophagitis: analysis of food impaction and perforation in 251 adolescent and adult patients. Clin Gastroenterol Hepatol 2008; 6: 598-600
• 25 Cheng E, Souza RF, Spechler SJ. Eosinophilic esophagitis: interactions with gastroesophageal reflux disease. Gastroenterol Clin North Am 2014; 43: 243-256
• 26 Kuchen T, Straumann A, Safroneeva E et al. Swallowed topical corticosteroids reduce the risk for long-lasting bolus impactions in eosinophilic esophagitis. Allergy 2014; 69: 1248-1254
• 27 Rajan J, Newbury RO, Anilkumar A et al. Long-term assessment of esophageal remodeling in patients with pediatric eosinophilic esophagitis treated with topical corticosteroids. J Allergy Clin Immunol 2016; 137: 147-156
• 28 Lieberman JA, Morotti RA, Konstantinou GN et al. Dietary therapy can reverse esophageal subepithelial fibrosis in patients with eosinophilic esophagitis: a historical cohort. Allergy 2012; 67: 1299-1307
• 29 Lucendo AJ, Arias A, De Rezende LC et al. Subepithelial collagen deposition, profibrogenic cytokine gene expression, and changes after prolonged fluticasone propionate treatment in adult eosinophilic esophagitis: a prospective study. J Allergy Clin Immunol 2011; 128: 1037-1046
• 30 Abu-Sultaneh SM, Durst P, Maynard V et al. Fluticasone and food allergen elimination reverse sub-epithelial fibrosis in children with eosinophilic esophagitis. Dig Dis Sci 2011; 56: 97-102