title: The diagnosis of primary eosinophilic oesophagitis in adults: missed or misinterpreted?
abstract: OBJECTIVE
  The diagnosis of adult eosinophilic oesophagitis (EOE) is rarely made in the UK despite projections of high frequency and prevalence within Western society. This study aimed to identify the frequency of diagnosis of EOE in our community, and to establish reasons for diagnostic failure or delay.
  
  
  METHODS
  The pathology records of all gastroscopies performed (67 840) in Northumbria NHS trust during the years January 2001-November 2008 were reviewed for oesophageal eosinophilia. Case notes and investigations were then inspected to identify patients with a diagnosis of EOE in accordance with American Gastroenterology Association guidelines.
  
  
  RESULTS
  In total, 37 patients fulfilled diagnostic criteria for EOE. The mean duration of symptoms before the diagnosis was 4 years (range 4 months-30 years) and 14 patients (38%) remained undiagnosed until the time of study. Reasons for diagnostic failure and delay included: delayed request for endoscopy in patients with dysphagia (49%, n=18 of 37); poor recognition of typical endoscopic appearances of EOE (16%, n=6 of 37); clinical mislabelling as gastro-oesophageal reflux disease (22%, n=8 of 37) and candida (13%, n=5 of 37); histological mislabelling as gastro-oesophageal reflux disease (19%, n=7 of 37), candida (5%, n=2 of 37), 'inflammation' (8%, n=3 of 37) and Barrett's oesophagus (3%, n=1 of 37); failed recognition or recording of maximal eosinophil concentrations within biopsies (35%, n=13 of 37). In 40% (n=15 of 37) of patients the decision to biopsy was based solely on a dysphagia protocol introduced in 2004. No cases were identified before the protocol implementation.
  
  
  CONCLUSIONS
  EOE is underdiagnosed in our community owing to lack of clinical suspicion, failure to biopsy, and histopathological misinterpretation. Educating clinicians and pathologists before planning an endoscopy may improve the diagnostic sensitivity.
authors.affiliation: Department of Surgery, Northumbria Healthcare NHS Foundation Trust, North Tyneside Hospital, North Shields, UK.
authors.forename: Venkatesh
authors.initials: V
authors.lastname: Kanakala
authors.forename: Christopher A
authors.initials: CA
authors.lastname: Lamb
authors.forename: Chris
authors.initials: C
authors.lastname: Haigh
authors.forename: Robert W
authors.initials: RW
authors.lastname: Stirling
authors.forename: Stephen E
authors.initials: SE
authors.lastname: Attwood
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D001471:Barrett Esophagus / Q000175:diagnosis / Q000473:pathology; D002177:Candidiasis / Q000175:diagnosis / Q000473:pathology; D003680:Deglutition Disorders / Q000175:diagnosis / Q000473:pathology; D003937:Diagnosis, Differential; D003951:Diagnostic Errors / Q000706:statistics & numerical data; D004802:Eosinophilia / Q000175:diagnosis* / Q000453:epidemiology / Q000473:pathology; D004941:Esophagitis / Q000175:diagnosis* / Q000453:epidemiology / Q000473:pathology; D005260:Female; D005764:Gastroesophageal Reflux / Q000175:diagnosis / Q000473:pathology; D006801:Humans; D008297:Male; D008875:Middle Aged; D012189:Retrospective Studies; D006113:United Kingdom / Q000453:epidemiology; D055815:Young Adult