The Eosinophilic Esophagitis Endoscopic Reference Score, or EREFS, is not only highly predictive of eosinophilic esophagitis (EoE) but also its responsiveness to treatment, which suggests it may be used as an outcome measure, researchers say.
A prospective study of 211 adults undergoing upper endoscopy to investigate symptoms of esophageal dysfunction compared the EREFS with consensus guidelines for diagnosis of eosinophilic esophagitis.
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The guidelines approach identified 67 cases of eosinophilic esophagitis and 144 control subjects without eosinophilic esophagitis. When these patients were assessed via the EREFS, researchers found multiple, highly significant differences between the cases and controls, with a mean total EREFS of 3.88 for cases and 0.42 for controls, according to a paper published online in Clinical Gastroenterology and Hepatology.
“On ROC [receiver operator characteristic] analysis, a model that contained all 5 components of the EREFS system as categorical variables had an AUC [area under the curve] of 0.946, indicating an excellent ability to predict EoE case status based on endoscopic findings alone,” wrote Dr. Evan S. Dellon and colleagues of the University of North Carolina at Chapel Hill.
In this model, a score of 2.0 or above showed a sensitivity of 88%, specificity of 92%, positive predictive value of 84%, negative predictive value of 94%, and accuracy of 91%.
Most of the score’s predictive ability was attributed to its inflammatory component, and less from the fibrostenotic score, which the authors suggested was due to the high prevalence of strictures in the control group.
The EREFS also improved significantly after treatment, in conjunction with endoscopic findings.
Total EREFS significantly decreased from 3.88 to 2.01, the inflammatory score decreased from 2.41 to 1.22, and the fibrostenotic score decreased from 1.46 to 0.89.
Histologic responders to treatment showed much more significant decreases in EREFS compared with nonresponders (Clin Gastro Hepatol. 2015, Sept. 12 [http://dx.doi.org/10.1016/j.cgh.2015.08.040]).
Researchers also examined the impact of weighing the various features of EREFS differently.
“The iterative analysis investigating weighing the EREFS features differently showed that increasing the weight of the exudate, rings, and edema score modestly increased the predictive power when the change in eosinophil counts was treated continuously and that increasing the weight of exudates and rings was beneficial with a threshold eosinophil count (less than 15 eosinophil/hpf) for response,” they reported.
Based on this finding, the researchers created a set of EREFS scores using these varied weights, and showed that doubling the exudates, rings, and edema scores achieved the score’s maximum responsiveness while still keeping the weighting system simple, although these changes did not alter the score’s overall predictive ability.
The EREFS score was developed as a way to standardize the description, recognition, and reporting of eosinophilic esophagitis, but its diagnostic utility and responsiveness to treatment were unknown, the authors said.
“This prospective study found that the EREFS classification has diagnostic utility for EoE,” they wrote. “Moreover, the score is responsive to treatment, decreasing significantly in histologic responders, and can be used as an outcome measure.”
The National Institutes of Health and the University of North Carolina Center for Gastrointestinal Biology and Disease funded the study. No conflicts of interest were declared.